Federal Report: Medicare Paid $5.1 Billion to Nursing Homes that Failed to Meet Quality-of-Care Standards

report.jpgThe United States Office of Inspector General (OIG) released a report in March 2014 summarizing 25 key findings and recommendations pertaining to health care facilities throughout the nation. The report, titled “Compendium of Priority Recommendations,” includes several findings related to long-term nursing home care facilities. For instance, the study pointed out that Medicare paid approximately $5.1 billion to nursing homes that failed to meet minimum quality-of-care standards, which regulate such items such as how nursing homes should provide basic wound care and manage patients’ medications and therapies. To address this issue, the OIG recommends that nursing homes improve care planning for residents. Care plans are developed by a team of physicians, nurses, social workers and therapists for each resident to ensure a patient’s needs are adequately addressed. Failure to develop such plans, or failure to follow care plans can actually harm residents. The OIG study found that 37 percent of nursing home residents either didn’t have a care plan, or had a care plan that was not effectively implemented.

In addition, the OIG determined that many nursing homes failed to provide adequate discharge plans for residents. Approximately one in three residents who left a facility didn’t have an appropriate discharge plan in place. Discharge plans often contain detailed and specific instructions for caregivers on how to treat the patient once he or she has left a nursing facility. When caregivers don’t have such instructions, they make errors in care, such as improperly administering medication. Such mistakes can lead to costly, yet preventable, hospitalizations.

Another key finding pointed out that one in three residents experienced some type of harm while staying at a nursing home. The finding also determined that 59 percent of harmful or adverse events were caused by poor care and could have been prevented. Such adverse events sometimes lead to hospitalizations. To address this issue, the OIG recommends that health inspectors identify causes of such harmful events and come up with ways to prevent them in the future.

The OIG report also uncovered large scale Medicaid fraud by nursing homes. In 2009, Medicaid made $1 billion in inappropriate payments to nursing facilities. In most cases, Medicaid made payments for services that were never provided. In other instances, Medicaid paid for services that were not medically necessary. In addition, Medicaid overpayments were sometimes the result of “upcoding”, a fraudulent billing practice in which a nursing home bills for a higher level of service than what was actually provided. To address this fraud and abuse, the OIG recommends that governmental agencies conduct more extensive audits and reviews of claims submitted by nursing homes to Medicaid.

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