Medicare and Medicaid services are the backbone for supporting elderly and disabled Americans. However, there have been many cases of individuals and parties abusing Medicare regulations for their own financial gain — and medical professionals and organizations within the healthcare industry are among them. However, no violations are invisible when the OIG is on the case. Here’s a look at one of the OIG’s current medicare investigations to curb fraud, waste, and abuse.
A Look at the OIG
Let’s begin by reviewing the OIG. Established in 1976, the Office of Inspector General (OIG) was created to fight fraud and abuse in Medicare and Medicaid. As the right hand of the HHS, they investigate allegations of misconduct and perform audits, evaluations, and more to ensure organizations aren’t straying from regulations and causing issues.
The OIG has recently set its sights on one particular group — skilled nursing facilities. As a new priority in their 2022 work plan, OIG plans to carry out Medicare investigations at skilled nursing facilities to check that they’re reporting costs in line with federal regulations.
OIG Medicare Fraud at Skilled Nursing Facilities
That might be a lot to take in, so let’s back up and go over the details of these Medicare investigations. Skilled nursing facilities (SNF) are organizations that offer high levels of care that demand advanced certifications and training. Patients commonly stay at skilled nursing facilities after their hospital visit to recover. These facilities work with related parties that are owned or directly connected to them, which can offer supply services that are needed to keep the main facility going.
Unfortunately, the relationships between skilled nursing facilities and their related organizations have been the subject of controversy in several areas across the country. One nursing home chain was picketed by an employee union over concerns that transactions made by their related organization were unlawful.
What’s Wrong With Their Transactions?
But why would this become a case of OIG Medicare fraud? Well, it has to do with the regulations surrounding the pricing of healthcare services. Medicare asks that the costs for nursing home services, supplies, and facilities have to be equal to the related organization’s expenses. This means that the prices for reimbursement have to be less than the actual cost for the organization.
The reason why these price regulations are enforced is to eliminate any incentives for skilled nursing facilities to profit from their transactions. Many legal operators have issued warnings that attempting to make money this way isn’t a good idea, but that hasn’t stopped some organizations from doing it — which is why the OIG has begun a Medicare investigation.
OIG Plans for Ending Medicare Fraud
The OIG has set out to determine whether skilled nursing facilities are reporting transactions that adhere to federal regulations. Additionally, they plan to identify whether the organizations’ violations are harming their ability to provide care — for example, care for patients could be weakened because of improper funding allocation. In other words, the OIG wants to investigate whether skilled nursing facilities are violating Medicare regulations and if they’re reducing the quality of patient care in the process.
Many places throughout the United States have also been asking for more transparency from skilled nursing facilities. New York, for example, passed a statute that makes nursing homes disclose any potential ownership changes. These law changes and Medicare investigations are happening to ensure facilities aren’t profiting financially at the expense of their patient’s well-being.
If you want to keep your healthcare organization in top form and compliant with legal regulations, reach out to MedTrainer today. We offer a wide assortment of programs, including OIG/SAM exclusion check software and much more to help you avoid healthcare fraud and streamline operations at your facility.