Breaking Compliance News Blog

We have an opioid problem

In the United States, 134 opioid-related deaths occur daily. In 2016, more than 60,000 Americans died from drug overdoses, and two-thirds of those deaths were opioid related. Fentanyl is now responsible for more overdose deaths (28.8%) than heroin. And, three out of four new heroin users first misuse prescription opioids.

In 2017, almost one-third of Medicare Part D beneficiaries received opioids. About 460,000 beneficiaries received high amounts of opioids; 71,000 beneficiaries were at serious risk of misuse or overdose; and almost 300 prescribers had questionable prescribing. Everyone agrees our country has an opioid problem.

In October, Health Services Management, Inc., the parent company for Huntsville Health Care Center, agreed to pay the U.S. government $5 million to resolve a whistleblower lawsuit that included allegations that the company billed Medicare and Medicaid for “worthless services” and services that were not provided. The settlement includes an agreement to enter a Corporate Integrity Agreement with the OIG. The whistleblower was an employee of the facility who claimed she witnessed patient physical and verbal abuse and neglect, inadequate care, and the absence of basic services including food and water.

The common response to this settlement is “This can’t happen in our building!!!” But how is it prevented? With a strong QAPI program.

Compliance is mandatory. Ultimately, many long term care operators see compliance as a lot of work—and perhaps a burden. While all of these things are true, compliance also keeps health care providers out of hot water and away from the headlines. Did you know that your compliance program is a tremendous asset that boosts your bottom line?

The benefits of your compliance efforts go far beyond adhering to the government mandate. One of the benefits of investing in compliance is that your census may see a boost!

Compliance improves quality.

Quality Assurance & Performance Improvement (QAPI) plans are an essential component of each and every effective compliance program.  An effectively monitored quality assurance program should advance your quality of care by addressing issues immediately, before they become widespread. By actively managing your quality indicators with a data-driven, team approach, your SNF can improve the processes that translate into better quality, better care, and satisfied residents. Providing quality care is, after all, the reason we are in this business. And it comes with a perk: quality care is the best PR you can find. Invest in your QAPI effort, and see the favorable online reviews and word of mouth campaigns grow. This will increase your census.

Compliance reduces readmissions.

By using their compliance programs to reduce hospital readmissions, SNFs can increase admissions from hospitals—and boost census. The Affordable Care Act’s Hospital Readmissions Reduction Program reduces hospital inpatient prospective payments based on a hospital’s percent of preventable Medicare readmissions. The government instituted this program because it believes a high readmission rate indicates poor pre- or post-discharge care. In response, hospitals are increasing their efforts to reduce readmission rates to the extent possible.

As a result, hospitals’ readmission problem has become SNFs’ problem, too. Hospital discharge planners are more likely to direct patients to nursing homes with lower readmission rates. By actively monitoring, managing and ultimately reducing readmissions with their QA programs, nursing homes can increase admissions from hospitals and boost census.

Learn about the other ways that compliance can boost your bottom line by downloading MPA's free whitepaper: Compliance Saves Money.

The US Attorney and OIG reported on June 14^th that a not-for-profit chain of nursing homes agreed to pay $750,000 to resolve False Claims Act violations related to the provision of worthless services. This False Claims Act enforcement represents a growing trend where the government can require SNFs to repay Medicare and/or Medicaid funds if the government believes the care is substandard and does not meet the conditions of participation.

On January 31, the OIG released its Work Plan for Fiscal year 2014 (which began on October 1, 2013). The Work Plan sets out the items the OIG will be reviewing during this fiscal year—and is a great tool to help Compliance Officers direct their compliance audits.

The work plan is about 100 pages, but don’t let that overwhelm you. It covers the entire health care industry, so the key is to find the pieces that apply to your organization. For example, the following items pertain to Nursing Homes:

The OIG recently released a review of SNF care and discharge plans. The OIG found that 37% of SNFs did not meet the care planning requirements or did not provide services in accordance with care plans. They go on to say that for 31% of stays, SNFs did not meet discharge planning requirements. The OIG calls for stricter oversight of SNF care and discharge plans as Medicare paid approximately $5.1 billion for stays in which SNFs did not meet the requirements.