The Centers for Medicare & Medicaid Services has pledged to issue new guidance on resident abuse after a federal watchdog found the agency was failing to use claims data to spot potential cases of neglect and abuse.

The Health and Human Services Office of Inspector General on Thursday posted a report showing that 93 of 100 sampled medical records “contained evidence of potential abuse or neglect’ of Medicare patients. That abuse or neglect was indicated by use of at least 1 of 64 related diagnosis codes across medical settings.

Among the 93 potential abuse cases, 14 were allegedly perpetrated by healthcare workers and 17 were related to incidents that occurred in medical facilities. Extrapolating that, the OIG said 27,522 of the 30,258 Medicare claims from 2019 and 2020 that it reviewed were supported by medical records that contained evidence of potential abuse or neglect, with 2,320 allegedly perpetrated by healthcare workers and 3,546 related to incidents that occurred in healthcare facilities. 

Many of those incidents, the OIG said, were going unreported to law enforcement, despite the role of healthcare providers who are legally required to make such reports.

“We maintain that Medicare data is a valuable resource that can be used to protect Medicare enrollees from abuse or neglect,” the OIG said in its audit report. “This is especially important because the majority of individuals enrolled in Medicare are elderly or disabled. Accordingly, CMS’s decision not to extract and analyze Medicare claims data with targeted diagnosis codes represents a missed opportunity to identify potential cases of abuse or neglect.”

The OIG recommended that CMS conduct data analyses to identify trends and high-risk areas in Medicare claims containing diagnosis codes indicating potential abuse or neglect. It also wants the agency to ask Medicare contractors to conduct targeted claim reviews to learn why some incidents may go unreported to law enforcement.

OIG also made it clear it wants word to trickle down to providers that more needs to be done when neglect or abuse is suspected or identified.The audit recommended CMS develop and share guidance with providers “to help ensure that incidents are reported in compliance with State mandatory reporting laws.”

And the OIG pressed the Medicare agency to assess whether it ought to strengthen existing conditions of participation requirements for reporting abuse or neglect of Medicare enrollees.

CMS did not respond by deadline Thursday to a McKnight’s Long-Term Care News request for comment and additional information on its planned response.

During a previous audit on the same topic, OIG said CMS demurred from pursuing some of its recommendations about tracking claims to find abuse patterns, noting that more than 80% of the incidents in the prior sample occurred in a home or public place. CMS said those cases do not fall under its jurisdiction, and also raised health information privacy concerns about sharing information with state officials to track patterns.

The OIG said its latest recommendations took both of these concerns into account to develop more “impactful and actionable” suggestions.

CMS told OIG during the audit period that it would “develop and share guidance to remind providers of their responsibility to report instances of potential abuse or neglect in accordance with their State licensure requirements.”

CMS also agreed to evaluate “all available evidence as it pertains to abuse and neglect when assessing the need for revisions” to its provider rules of participation. 
CMS made that pledge this September, just over a year after updating abuse and neglect requirements in Phase 3 guidance issued in 2022.