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Posts tagged "Compliance"

Compliance and Ethics Program Implementation

Effective November 28, 2019, the Phase III requirements of the Long Term Care Requirements of Participation require all nursing facilities to implement a Compliance and Ethics program consistent with the dictates of 42 CFR § 483.85 (F895). The Rule obligates facilities to have a written compliance and ethics program in place that is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act and in promoting quality of care. The Regulation lists multiple requirements for the program, which relate to historical compliance guidance issued by other federal agencies, including the Office of the Inspector General.

Government Continues To Focus On Therapy Issues In Nursing Homes

The provision of therapy services continues to be a focal point of government regulators. In its 2016 Work Plan, the OIG states that it will continue to review the provision of therapy in nursing homes, citing past findings of overutilization and fraudulent billing of such services. The OIG, in conjunction with the U.S. Department of Justice, has been active in prosecuting alleged therapy billing compliance issues, resulting in multi-million dollar settlements with nursing home providers, with several high-profile investigations still pending. RAC and ZPIC audits focusing on therapy services continue throughout the country. In September 2015, the OIG issued a report entitled "The Medicare Payment System For Skilled Nursing Facilities Needs To Be Reevaluated" which concluded that Medicare payments for therapy services greatly exceeded nursing facility costs, and that the current system encourages nursing homes to bill therapy services at the highest levels possible, in order to maximize reimbursement, without a corresponding demonstration of beneficiary need.

Federal Court Provides First Decision on ACA 60 Day Self-Disclosure of Overpayment Rule

The Affordable Care Act requires providers to return overpayments to federal health care programs within 60 days of identification. Neither the ACA nor federal regulations specifically define when an overpayment is "identified" for purposes of beginning the 60-day clock. In 2012, CMS issued a proposed rule (never finalized) that would define an overpayment to be identified when a person has actual knowledge of, or acts in deliberate ignorance/reckless disregard of the overpayment's existence. The provider community rejected this definition as being too broad, arguing that an overpayment should only be "identified" when the actual amount of the overpayment was determined.

CMS Proposes Compliance and Ethics Program Requirements for Long Term Care Providers

The Affordable Care Act required long term care provider to implement a corporate compliance plan by March 23, 2013. Despite the Act's requirements, neither CMS nor the OIG have promulgated regulations to carry out this statutory mandate. However, in the July 16, 2015 Federal Register.pdf, containing the proposed changes to the Requirements of Participation for long term care facilities, CMS proposes to add a new regulation, 42 CFR 483.85, requiring a nursing facility's operating organization to implement a compliance and ethics plan consistent with the regulatory provisions. The proposed rule establishes basic standards that apply to all operating organizations, and then imposes additional standards on those organizations with five or more facilities.

OIG Issues New Compliance Guidance for Health Care Boards

On April 20, 2015, the OIG released a document entitled "Practical Guidance for Health Care Governing Boards on Compliance Oversight." http://oig.hhs.gov/newsroom/news-releases/2015/guidance-release2015.asp

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