For 2024, healthcare fraud has already been rampant, according to the U.S. Department of Health and Human Services Office of Inspector General. 

But on Jan. 19, the OIG took a specific stance with regard to updates in its assessment of nursing homes and nursing home fraud, per updated guidance on oversight by the OIG.

OIG reported some pretty sensational, major healthcare fraud enforcement actions have already taken place in 2024. Here are the excerpts for the ones reported just in January and early February this year:

  • Serial healthcare fraudster sentenced for $234 million Medicare fraud scheme
  • Home health company owner sentenced for nearly $2.8 million Medicare fraud scheme
  • Kentucky lab agrees to $4.9 million civil judgment, and drug treatment center enters settlement to pay $2.2 million to resolve false claim allegations
  • Florida man arrested in role in multimillion-dollar Medicare scheme based on fraudulent billing for durable medical equipment
  • Man sentenced for $336 million healthcare fraud

Narrowing in on nursing home fraud

Each of the above schemes involved particular nefarious actors seeking to bilk the government out of federal dollars in an attempt to commit outright fraud. But when it comes to nursing home fraud, the OIG takes more of a nuanced stance, not necessarily focusing on willful and wanton conduct as in the above fraud investigations.

In particular, the OIG listed in its guidance that it has a number of areas that it seeks to focus on, but these areas have less to do with necessarily “bad” actors as outlined above, but more with a focus on nursing homes that are failing to protect residents. As a result, the OIG suggests strengthening oversight of nursing homes to promote better quality of care. 

Below are the key areas OIG seems to focusing on lately with regard to nursing home enforcement:

1. Protect residents from fraud, abuse and neglect and promote quality of care

The OIG seeks to investigate nursing homes that “victimize” residents in the setting. OIG intends to focus on neglect and inadequate care by nursing facilities and address those violations through False Claims Act cases with the help of the Department of Justice. 

The focus here seems to be on substandard care that the government does not want to pay for, and where that substandard care is persistent and, thus, the basis for a False Claims Act case. Here, OIG is highlighting its proclivity toward ferreting out fraud through the use of the False Claims Act, its weapon of choice against nursing homes.  

2. Promote emergency preparedness and response efforts

OIG is focusing on nursing home administrators who fail to plan and execute appropriate emergency preparedness response policies and procedures to deal with emergencies such as infectious disease, natural disasters and safety threats.  The OIG is focusing on this area again, as it did in 2020 with COVID-19, to protect residents during an emergency.

3. Strengthen frontline oversight

OIG is also focusing on state on-site surveyors at nursing facilities, and OIG is clearly not pleased with each state agency’s effectiveness in surveying facilities for non-compliance with federal requirements. As a result, OIG will continue to point out shortcomings with state-conducted on-site surveys in an effort to strengthen and bolster frontline surveys of nursing homes.f

4. Support federal monitoring of nursing homes to mitigate risks to residents

Following up No. 3 above, OIG will work with the Centers for Medicare & Medicaid Services to focus on ways that CMS can better monitor state agencies to ensure that nursing homes meet federal requirements for quality and safety. OIG is calling on CMS to strengthen its oversight of state agencies and to provide further guidance to states regarding the survey process.  According to its guidance, OIG intends to utilize and leverage data from nursing homes to increase its oversight of nursing homes and, in particular, state agencies that survey nursing homes.

In all, nursing homes should not think the OIG is focused only on the egregious healthcare fraud that most often appears in the headlines. OIG is clearly out to ferret out fraud in nursing homes, especially through the survey process.  

Nursing homes can expect increased enforcement based upon this OIG guidance, which is not good news for nursing homes that have faced increased enforcement throughout the pandemic and through today from both CMS and state agency surveyors.  

Neville M. Bilimoria is a partner in the Chicago Office of the Health Law Practice Group and member of the Post-Acute Care And Senior Services Subgroup at Duane Morris LLP.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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