Literature Review

[OIG] Health Care Fraud and Abuse Control Program Fiscal Year 2023 ReportOIG press release; 12/6/24Today, OIG, the Department of Health and Human Services, and the Department of Justice released the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2023, which details the latest interagency efforts to decrease health care fraud and recover over $1.8 billion. [Click link above to read the Fiscal Year 2023 Report.]

CGS Administrators, LLC, did not reopen and recalculate most selected hospices’ caps for years prior to 2020 USA HHS Ofice of Inspector General (OIG), Washington, DC; issued 11/27/24, posted 12/4/24Why OIG Did This Audit: ... Our audit determined whether CGS accurately calculated cap amounts and collected cap overpayments in accordance with CMS requirements. This audit is part of a series that reviewed MAC calculations and collections of hospice aggregate and inpatient cap overpayments.What OID Recommends: [... that CGS] 

OIG issues nursing facility industry segment-specific Compliance Program Guidance; first in a series in Furtherance of its Modernization Initiative Butzel - Attorneys and Counselors Client Alerts; 11/22/24 On November 20, 2024, the U.S. Department of Health & Human Services, Office of Inspector General (“OIG”) issued the first Industry Segment-Specific Compliance Program Guidance (“ICPG”), which applies to the Nursing Facility Industry. This follows from the OIG’s Modernization Initiative to update publicly available resources for the healthcare industry first announced in September 20211 and finalized in April 2023. This ICPG comes just over a year after the OIG issued the General Compliance Program Guidance (“GCPG”) that kicked off the OIG’s efforts to modernize and consolidate numerous Compliance Program Guidance documents issued between 1998 and 2008. Editor's note: Click here to download the U.S. HHS OIG's 59-page November 2024 "NURSING FACILITY Industry Segment-Specific Complicance Program Guidance." A word search finds 30 references to "hospice."

CMS to surveyors: Keep eyes open for hospice fraud Hospice News; by Jim Parker; 11/14/24 The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a memo to accreditation bodies and state agencies advising surveyors to watch out for potential hospice fraud. The memo directs surveyors to refer issues to CMS if they suspect fraudulent activity. These actions were spurred by a rash of fraudulent hospices that have emerged primarily in California, Texas, Nevada and Arizona. “While the primary purpose of [state agencies and accreditation organization] surveys is to determine compliance with the Medicare Hospice CoPs, there are several elements of the survey process that can uncover concerns that would necessitate a referral to CMS for potential fraud,” CMS indicated in the memo. 

East Lansing caregiver sentenced for role in freezing death of elderly womanOIG press release; 9/17/24Colleen Kelly O’Connor, 58, of East Lansing, was sentenced to two years of probation with the first 6-months in jail by Judge Cori E. Barkman of the 29th Circuit Court in Clinton County for her role in the death of an 82-year-old woman in December 2022, announced Michigan Attorney General Dana Nessel. O’Conner was convicted in June by a Clinton County jury of one count of Vulnerable Adult Abuse — Second Degree. The victim, who was under O’Connor’s care at Vista Springs Imperial Park at Timber Ridge, an assisted living facility in Clinton County, died of exposure after being left unsupervised. O’Connor was also ordered to pay $1,115.00 in restitution to the daughter of the victim... During the very early morning hours of December 23, 2022, O’Connor twice observed the victim attempt to go outside without appropriate attire into a blizzard with single-digit temperatures, subzero windchill, and blowing and drifting snow. As a caregiver, O’Connor recklessly failed to act to prevent the victim from going outdoors into the storm, resulting in her death. A snowplow driver found the victim in the parking lot around 7 a.m., partially buried in snow.

States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model CMS.gov; 7/2/24 On July 2, 2024 CMS announced that Connecticut, Maryland, and Vermont will be the first state participants in the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. Hawaii will also participate, pending satisfaction of certain requirements. Applications to participate in Cohort 3 of the model are due August 12, 2024 at 3:00 p.m. EST (Cohort 3). Eligibility requirements and additional model details can be found in the NOFO.  To stay up to date on model announcements, events, and resources, please sign up for the AHEAD Model listserv.

Examining how improper payments cost taxpayers billions and weaken Medicare and Medicaid HHS-OIG; by Christi A. Grimm, Inspector General, Office of Inspector General, U.S. Department of Health and Human Services; 4/16/24 HHS Inspector General Christi A. Grimm Testifies Before the U.S. House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations on April 16, 2024. IG Grimm briefs members on HHS-OIG's work to address improper payments in Medicare and Medicaid managed care programs. Click here to watch the testimony.

OIG’s Audit of Nursing Home Workers in Louisiana Finds Flaws in Background Check ProcessSkilled Nursing NewsDecember 6, 2023A federally commissioned report released Wednesday found that nursing homes in Louisiana failed to complete background checks on a portion of their non-licensed employees. In conducting the audit to examine whether Louisiana nursing homes complied with federal requirements for backgrounds checks, the Office of Inspector General chose a sample of 9 Louisiana nursing homes out of a total of 276 licensed facilities in the state, basing its sample size on a variety of risk factors and on the need to select nursing homes in urban and rural settings, the agency said. ... The OIG report states. “Although Federal requirements do not specify the methods or types of information that should be considered for a background check to be regarded as having been satisfactorily completed, we identified potential limitations in the nursing homes’ background check searches and adjudication methods for 49 of the 209 non-licensed employees we reviewed.” In response to OIG’s findings and recommendations, Louisiana has agreed to update its standard survey process to ensure routine monitoring of nursing homes’ compliance with background check requirements by reviewing a sample of 5% of current non-licensed staff and by directing nursing homes to conduct self-audits of current personnel files. ... Among the findings, some disturbing practices emerged. Of the 9 nursing homes closely investigated, six nursing homes, and some of the staffing companies with which they contracted, had employee background check searches conducted that did not include a statewide search of State police records.

Government expects to recover more than $3B from healthcare fraud, misspent funds in fiscal year 2023Healthcare DiveDecember 4, 2023The HHS’ Office of the Inspector General is expected to recover more than $3.44 billion in fiscal year 2023 as a result of investigations into fraud and misspent funds in Medicare, Medicaid and other government health programs, according to the agency’s latest report.