The Department of Health and Human Services (DHHS) Office of Inspector General’s (OIG) office is quickly ramping up its 2022 audit program as identified in its Active Work Plan. There is no shortage of expenditures, regulatory requirements and collected data to audit, and nursing facilities and hospitals have a few big-ticket reviews directed their way. These audits also reflect continuing priorities of the OIG as described in their 2021 Top Unimplemented Recommendations publication. Overall, OIG is looking at efforts that would bring about positive results in “cost savings, public health and safety, and program effectiveness and efficiency.” We highlight below four audits that have kicked off in recent months and advise that your compliance and regulatory staff give some attention to these areas.
COVID-19 Vaccination Status of Nursing Home Staff
Right out of the gate, OIG is going to be auditing nursing facilities’ compliance with the amended 42 vaccinated against COVID-19. The regulations allow nursing homes to grant staff exemptions from the vaccination requirements based on Federal law (e.g., for specific medical and religious reasons). The regulations, among other things, also require nursing homes to track and securely document the vaccination status of staff, exemptions requested, and exemptions granted. OIG has indicated from its review of collected data that while nursing homes have made significant progress in vaccinating their residents, approximately one in five nursing home staff were not vaccinated as of the end of 2021. The effective date of the regulations varies by State, but all States must comply by March 21, 2022. Facilities should ensure that exemptions are well documented.
Nursing Home Capabilities and Collaboration to Ensure Resident Care During Emergencies – Development of New Key Performance Indicator
OIG recognizes that nursing facilities face a broad range of challenges from public emergencies, such as emerging infectious disease outbreaks and natural disasters, and wants to ensure that facilities develop and maintain an emergency preparedness program that addresses a wide range of issues. OIG is aware that recent emergencies have exposed weaknesses in nursing home emergency preparedness. This study will survey the challenges nursing homes face in preparing for emergencies, with specific focus on their capabilities for managing resident care during emergencies, as well as their collaboration with community partners (e.g., other health care providers, emergency management agencies). OIG will also use a portion of the data collected for this study for a new Key Performance Indicator that will track the prevalence and severity of challenges experienced by nursing homes over time.
Hospital’s Compliance with the Provider Relief Fund (PRF) Balance Billing Requirement for Out – of – Network Patients
Several Covid-19 legislative Acts appropriated a combined $178 billion in relief funds to hospitals and other health care providers. This funding is intended to reimburse eligible health care providers for health care-related expenses or lost revenue attributable to COVID-19. Hospitals must attest that they will not pursue the collection of out-of-pocket payments from presumptive or actual COVID-19 patients in excess of what the patients otherwise would have been required to pay if the care had been provided by in-network providers. OIG refers to this limitation on balance billing, commonly referred to as “surprise billing,” as the “balance billing requirement.” OIG will be auditing to determine whether hospitals that received PRF payments and attested to the associated terms and conditions complied with the balance billing requirement for COVID-19 inpatients. They will assess how bills were calculated for out-of- network patients admitted for COVID-19 treatment, review supporting documentation for compliance, and assess procedural controls and monitoring to ensure compliance with the balance billing requirement.
Medicare Payments for Inpatient Claims with Mechanical Ventilation
The OIG has long had mechanical ventilation on its audit radar, and COVID-19 of course put special focus on this intervention. OIG will review Medicare payments for inpatient hospital claims with certain Medicare Severity Diagnosis Related Group (MS-DRG) assignments that require mechanical ventilation to determine whether hospitals’ DRG assignments and resultant Medicare payments were appropriate. For certain MS-DRGs to qualify for Medicare coverage, a beneficiary must have received more than 96 hours of mechanical ventilation. Previous OIG reviews identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive at least 96 hours of mechanical ventilation. Hospitals should be conducting regular audits on its respiratory therapy interventions and long-term mechanical ventilation patients.
The Jolley Law Group’s health law team is continuously monitoring information released by HHS and OIG regarding its auditing priorities. Please contact us for additional information and guidance on your compliance and regulatory risk program.
