Abuse or neglect, including among skilled nursing facility beneficiaries, resulted in around 1 in 5 high-risk hospital emergency room Medicare claims in 2016, a new government report finds.
Even more alarming: Many skilled nursing facilities failed to report these incidents to their survey agencies, according to the Office of Inspector General’s new “Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated.”
Provider leaders told McKnight’s on Wednesday that caregivers are not willfully ignoring abuse cases but rather confused by “vague” reporting guidance. More caregiver education is needed, all sides agreed.
There were likely 7,831 high-risk hospital ER Medicare claims for Medicare beneficiaries residing at SNFs that resulted from incidents of potential abuse or neglect during 2016, according to the OIG. Investigators came to this conclusion by looking at 256 high-risk hospital ER Medicare claims from eight states, out of more than 37,000 total claims.
Of the 51 claims studied that were associated with incidents of potential abuse or neglect, the agency determined that 42 facilities did not report the incident to the survey agencies. In 35 instances, SNFs indicated their awareness of circumstances but did not feel they met a reporting threshold.
“We have to get to the root cause of any finding,” Assistant Regional Inspector General Curtis Roy told McKnight’s on Wednesday. “For those who did respond, there seems to be some general confusion regarding what is and what isn’t reportable.”
The OIG recommended that the Centers for Medicare & Medicaid Services work with states to improve training and better identifying what needs to be reported.
“Clarify the guidance — it really gets back to that,” Roy said.
The American Health Care Association agreed with a need for more transparent reporting.
“While the OIG report shows only 0.4% of the 1.9 million residents in skilled nursing facilities who went to the emergency room experienced some type of abuse, more work is needed to reduce those reports to zero,” said AHCA Senior Vice President of Quality and Regulatory Affairs David Gifford, M.D. “The current CMS definition is of neglect is vague and creates confusion about what should be reported. The majority of the facilities contacted by the OIG for this report didn’t believe their situation met the CMS definition for reporting.”
LeadingAge seconded a call for more training on abuse protocols.
“LeadingAge has long recommended, as OIG does in these reports, the importance of and the need for continued training by CMS of state survey agencies,” said the group’s president and CEO, Katie Smith Sloan.
CMS’s ‘missed opportunity’
The second new report from the OIG claims the Centers for Medicare & Medicaid Services’ failure to use certain Medicare claims data represents a “missed opportunity to identify potential cases of abuse or neglect.”
Out of more than 30,000 Medicare claims indicating abuse or neglect, more than 2,500 were allegedly perpetrated by a healthcare worker. That’s according to a new report titled “CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect” from OIG. More than 3,300 were related to incidents that occurred in a medical facility.
CMS, however, disagrees with the government watchdog’s recommendation to compile diagnosis codes indicating potential phsycial or sexual abuse or neglect, and to use the complete list of diagnosis codes to conduct periodic data extracts of all Medicare claims related to abuse codes.
CMS argues that system would be ineffective at tackling problems, noting that claims data “may not be timely” because providers have up to 12 months after the date of a service to submit a claim. Assistant Regional Inspector General Curtis Roy, however, noted that study samples were collected in an average of 32 days from service, and more than 90% of claims in the sample were submitted in 90 days or less.
Sampling is “is an effective technique to monitor a system of internal controls over the healthcare system. You need that feedback loop,” Roy told McKnight’s. “If we’re relying on mandated reporters to identify instances of unreported potential abuse and neglect, this is where the data mining extraction tests that.”