Healthcare: Compliance Risk Areas
This is a draft cheat sheet. It is a work in progress and is not finished yet.
Skilled Nursing Facilities must perform Annual Risk Assessments to determine, rank and prioritize focus areas for the work plan. Sometimes, this task can be overwhelming. In order to help streamline this task, it is wise to reference The Budget Reconciliation Act (OBRA) of 1987, and past OIG Reports that highlight areas of concern for by Skilled Nursing Facilities:
Every Skilled Nursing facility must implement systems, policies and procedures to ensure the resident’s:
Freedom of choice
Reasonable accommodation of individual needs.
The Federal Register
“Implementing an effective compliance program in a nursing facility may require a significant commitment of time and resources by all parts of the organization. However, superficial efforts or programs that are hastily constructed and implemented without a long term commitment to a culture of compliance likely will be ineffective and may expose the nursing facility to greater liability than if it had no program at all. Although an effective compliance program may require a reallocation of existing resources, the long term benefits of establishing a compliance program significantly outweigh the initial costs.
In short, compliance measures are an investment that advance the goals of the nursing facility, the solvency of the Federal health care programs, and the quality of care provided to the nursing home resident.”
Top Risk Areas Resident Rights Include
1. Discriminatory admission or improper denial of access to care
2. erbal, mental or physical abuse, corporal punishment and involuntary seclusion
3. Inappropriate use of physical or chemical restraints
4.. Failure to ensure that residents have personal privacy and access to their personal records upon request and that the privacy and confidentiality of those
5. Denial of a resident’s right to participate in care and treatment decisions
6. Failure to safeguard residents’ financial affairs
7. Billing for items or services not rendered or provided as claimed
8. Submitting claims for equipment, medical supplies and services that are medically unnecessary
9. Submitting claims to Medicare Part A for residents who are not eligible for Part A coverage
10. Duplicate billing
11. Failing to identify and refund credit balances
12. Submitting claims for items or services not ordered
13 Knowingly billing for inadequate or substandard care.
14. Providing misleading information about a resident’s medical condition on the MDS or otherwise providing inaccurate information used to determine the RUG assigned to the resident
15. Upcoding the level of service provided
16. Billing for individual items or services when they either are included in the facility’s per diem rate or are of the type of item or service that must be billed as a unit and may not be unbundled
17. Billing residents for items or services that are included in the per diem rate or otherwise covered by the third-party payor
18. Altering documentation or forging a physician signature on documents used to verify that services were ordered and/ or provided
19. Claims processing error