On November 6, 2023, the Office of Inspector General (OIG) released an updated General Compliance Program Guidance (GCPG) manual, the first significant update in 15 years. The updates made provide clearer guidance on what an effective compliance program is, and how healthcare organizations can implement them.  The following seven elements make up an effective compliance program. 

1. Written policies and procedures
2. Compliance leadership and oversight
3. Training and education
4. Effective lines of communication with the Compliance Officer and disclosure program
5. Enforcing standards with consequences and incentives
6. Risk assessment, auditing, and monitoring
7. Responding to detected offenses and developing corrective action initiatives

Written Policies and Procedures
Policies and procedures outline how your organization and employees are expected to behave. In healthcare, policies and procedures are essential for several reasons. They ensure that patient information is handled correctly and secured, help to create a safe work environment for employees while protecting patients, and ensure ethical billing practices by preventing fraud, waste, and abuse.

Earlier this year, CMS announced the start of the Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review program. This is in response to a 15.1% increase in improper payments for 2022 services, as projected by the Comprehensive Error Rate Testing (CERT) program—likely driven by the change in payment model from Resource Utilization Group (RUG) IV to the PDPM (Patient-Driven Payment Model) in October 2019.

As a result, CMS has directed all Medicare Administrative Contractors (MACs) to conduct a pre-payment review of five SNF claims for all providers nationwide, with few exceptions. Unless your SNF is already under medical review or is considered a low-volume provider (fewer than five Part A claims per calendar year), you will be subject to the Targeted Probe and Educate (TPE) program and may have already received notification from your MAC.

Are your employees putting your business at risk with AI?

At Model, we assist numerous clients with their Cybersecurity Compliance Frameworks and Policies. Model utilizes a leading vCISO Compliance tool that recently introduced a Generative AI Cybersecurity Control. I thought you might be interested in seeing the list of questions it raises:

Skilled nursing facility (SNF) budgets have been stretched thin for years, with most providers cutting any unnecessary items from their expenses. However, some administrators are still seeing their revenue decreasing.

Many point to the two-year PDPM parity adjustment recalibration, continued effects of COVID-19, and inflation as the cause of decreasing SNF revenue. However, have you considered how managed care receivables, SNF Quality Reporting Program (QRP) outcomes, and ranking in the SNF Value Based Purchasing (VBP) program may be impacting your bottom line? These often-overlooked factors may reveal opportunities to increase income.

HHI is fielding many questions regarding the calculations for Length of Stay (LOS). Skilled nursing facilities across the country track the Clinically Anticipated Stay (CAS), otherwise known as Length of Stay (LOS), to determine the amount of days a patient resides in the nursing home. Data collection is the foundation for monitoring progress, but, in itself is a daunting task. CMS uses LOS in the SNF QRP program, for patients discharged to the hospital and for patients who return to the Emergency Room or hospital within 30 days of discharge from the SNF. The accuracy and consistency of these figures is critical for care, operations, outcomes and analysis.

What calculations are being used?

In early December, Centers for Medicare & Medicaid Services (CMS) finalized the Medicare Physician Fee Schedule for 2021, reflecting significant cuts to a variety of providers. Physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) were initially going to be impacted by a reimbursement reduction of approximately 9%. In late December, in response to intense advocacy by organizations representing the 37 professions affected by the cuts, Congress approved a new omnibus and COVID-19 relief package that reduced the planned cuts to approximately 3% and put the 2% sequestration reduction on hold. The omnibus bill sets the payment rate for CY2021, but the sequestration hold expires on March 31, 2021. At that point, the 2% sequestration reduction will return for all Medicare claims. While this is certainly an improvement over the proposed 9% cut, the new cuts will still prove to be unsustainable for many providers.

So how can you mitigate these reductions in your Part B therapy billings? A key aspect of mitigating these losses is the overall management of your therapy operation. There are some obvious and some not-so-obvious areas where mitigation may be possible. In this article, we will discuss four of them: Multiple Procedure Payment Reduction (MPPR) Policy, the Medicare 8-Minute Rule, Productivity, and Staff Education.

Facilities face supply chain disruptions and staffing shortages

Faced with a global pandemic now affecting everyday life across the country, the U.S. healthcare system is struggling to cope with potential staffing shortages and supply chain disruptions.

“Everybody is stressed,” said Bill McGinley, President and CEO of the American College of Healthcare Administrators, or ACHCA. “Most of the stress is coming from the conflicting information put out by the CDC, CMS and various state agencies. Often it is conflicting and changes from day to day. It is very hard to keep up.”

Stotler Hayes Group Attorney, Nathan Peters, presented at the Texas Healthcare Association’s Board of Directors meeting on August 21st, 2019. Nathan shared two updates on how Stotler Hayes Group’s (SHG) Texas-based attorneys are successfully fighting to recover every Medicaid dollar available for our clients, and all Texas providers. SHG attorneys have litigated two major issues with the Texas Health and Human Services Commission (THHSC) and both could significantly impact future Medicaid payments in Texas. The issues the cases have dealt with include (1) the THHSC’s denial of an application for failing to exclude inaccessible resources for incapacitated Medicaid Applicants and (2) THHSC’s improper restrictions on Incurred Medical Expenses (IME). By some estimates, the IME payments could alone boost Medicaid provider payments over $40 million annually.

Unlike some state Medicaid agencies, THHSC previously refusing to exclude certain resources when reviewing Medicaid applications for incapacitated individuals. This policy is leading to a significant loss in payments for providers, because affected providers are left without a payor source until the incapacitated resident can secure a guardian with the authority to spend down their resources. Unfortunately for these providers, securing a guardian and spending down resources for incapacitated individuals is often a lengthy and complicated process. However, SHG’s recent victory in the case of Tex. HHS Comm’n v. Marroney, 2019 Tex. App. LEXIS 4298, 2019 WL 2237885 (Tex. App. – Austin May 24, 2019, Pet. Denied) should lead the THHSC to change its policy and start excluding inaccessible resources for incapacitated residents.

Deadline Looming for Mandatory Nursing Home Compliance Programs

Skilled Nursing Facilities have until November 28, 2019 to adopt and implement a compliance program that meets the elements set out by the Center for Medicare and Medicaid Services (CMS). Beginning on that date, state survey agencies will start assessing nursing homes’ compliance programs as an additional condition of participation in Medicare and Medicaid. Issued in 2016 as part of CMS’s revised Part 483 of Title 42 (“Requirements for States and Long Term Care Facilities”), the CMS compliance program elements are functionally identical to those from the Office of Inspector General for Health and Human Services (OIG).¹ Already the standard for effective compliance programs, the OIG elements are used to measure an organization’s culpability when federal fraud and abuse laws are violated. Specifically, the OIG considers “the existence of an effective compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative sanctions.”

Earlier this month, the Center for Medicare and Medicaid Services (“CMS”) issued a final rule repealing its’ prior rule prohibiting long-term care providers (“LTC”) from entering into pre-dispute, binding arbitration agreements with their residents. This change takes effect September 16, 2019 and comes after years of protracted rule-making efforts, public comment, and litigation that began in October 2016 when CMS issued a final rule prohibiting the agreements in nursing facilities and ended up in the U.S. Supreme Court in May 2017.

This new final rule represents a win, albeit a limited one, for the long-term care industry. On one hand, the ability to pursue arbitration represents a real opportunity for facilities to reduce liability and minimize the costs of potential litigation with residents by eliminating discovery, attorneys’ fees, and other related litigation expenses. On the other hand, the final rule contains a number of provisions, intended to protect nursing home residents, which may cause providers concern as they evaluate the benefit of adding these provisions to their Admission Agreements.

The new year brings new opportunities and challenges to the senior living industry. With all the changes in process, it’s a good time to revisit your strategy and evaluate what decisions can make you successful in 2018.

Investment in Senior Living