Show Menu

Healthcare: Compliance Risk Areas Cheat Sheet (DRAFT) by [deleted]

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:

Resident Rights

Every Skilled Nursing facility must implement systems, policies and procedures to ensure the reside­nt’s:

Dignified existence
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