Long-Term Care

Health Hippo: Long-Term Care

Health Hippo: Long-Term Care


Time is that wherein there is opportunity, and opportunity is that wherein there is no great time.

Long-term care is a range of services including both skilled medical care and assistance with activities of daily living (ADLs), such as: bathing, dressing, toileting, transferring and eating. It can also include assistance with cooking, housework, medications, shopping and the like. Long-term care services may be provided in nursing homes and assisted living facilities, but are being provided increasingly more commonly at home. Hospice care can be provided at home or in a facility to people certified to have less than six months to live.

U.S. Code

  • Protecting Access to Medicare Act of 2014 The 2014 “doc fix” is in. Includes another short-term fix to the SGR without any permanent solution, as well as provisions with significant impact on skilled nursing facilities.
  • Affordable Care Act: Long-term care provisions
    • Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies.
    • Sec. 3024. Independence at home demonstration program.
    • Sec. 3026. Community-Based Care Transitions Program.
    • Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries.
    • Sec. 6101. Required disclosure of ownership and additional disclosable parties information.
    • Sec. 6102. Accountability requirements for skilled nursing facilities and nursing facilities.
    • Sec. 6103. Nursing home compare Medicare website.
    • Sec. 6104. Reporting of expenditures.
    • Sec. 6105. Standardized complaint form.
    • Sec. 6106. Ensuring staffing accountability.
    • Sec. 6107. GAO study and report on Five-Star Quality Rating System.
    • Sec. 6111. Civil money penalties.
    • Sec. 6112. National independent monitor demonstration project.
    • Sec. 6113. Notification of facility closure.
    • Sec. 6114. National demonstration projects on culture change and use of information technology in nursing homes.
    • Sec. 6121. Dementia and abuse prevention training.
    • Sec. 6201. Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers.
    • Sec. 6301. Patient-Centered Outcomes Research.
    • Sec. 6302. Federal coordinating council for comparative effectiveness research.
    • Sec. 6701. Elder Justice Act.
    • Sec. 6702. Definitions.
    • Sec. 6703. Elder Justice.
    • Sec. 10202. Incentives for States to offer home and community-based services as a long-term care alternative to nursing homes.
    • Sec. 10315. Revisions to home health care provisions.
    • Sec. 10325. Revision to skilled nursing facility prospective payment system.
    • Sec. 10605. Certain other providers permitted to conduct face to face encounter for home health services.
    • Sec. 10801. CLASS program.
  • Balanced Budget Act Payment for SNF, HHC & Hospice.
    • Sec. 4431 Extension of
      cost limits.

    • Sec. 4432 Prospective
      payment for skilled nursing facility services.

    • Sec. 4441 Payments for
      hospice services.

    • Sec. 4442 Payment for
      home hospice care based on location where care is

    • Sec. 4443 Hospice care
      benefits periods.

    • Sec. 4444 Other items
      and services included in hospice care.

    • Sec. 4445 Contracting
      with independent physicians or physician groups for hospice
      care services permitted.

    • Sec. 4446 Waiver of
      certain staffing requirements for hospice care programs in
      nonurbanized areas.

    • Sec. 4447 Limitation on
      liability of beneficiaries for certain hospice coverage

    • Sec. 4448 Extending the
      period for physician certification of an individual’s terminal

    • Sec. 4449 Effective

    • Sec. 4601 Recapturing
      savings resulting from temporary freeze on payment increases
      for home health services.

    • Sec. 4602 Interim
      payments for home health services.

    • Sec. 4603 Prospective
      payment for home health services.

    • Sec. 4604 Payment based
      on location where home health service is furnished.

    • Sec. 4611 Modification of
      part A home health benefit for individuals enrolled under part

    • Sec. 4612 Clarification
      of part-time or intermittent nursing care.

    • Sec. 4613 Study on
      definition of homebound.

    • Sec. 4614 Normative
      standards for home health claims denials.

    • Sec. 4615 No home health
      benefits based solely on drawing blood.

    • Sec. 4616 Reports to
      Congress regarding home health cost containment.

    • Subtitle
      Programs of All-Inclusive Care for the Elderly (PACE)

    • Sec. 4801 Coverage of PACE
      under the medicare program.

    • Sec. 4802 Establishment of
      PACE program as medicaid State option.

    • Sec. 4803 Effective date;

    • Sec. 4804 Study and

Code of Federal



  • Skilled Nursing Facilities
    • Green Oaks Health and Rehabilitation (DAB 2014)(upholding nursing home non-compliance penalty and immediate jeopardy finding)
    • In the Case of Restore Management Company (MAC 2013) (the Council modified the ALJ’s decision and made specific determinations regarding the appropriate RUG codes at issue)
    • In the Case of Meadow View Manor (MAC 2012) (The record demonstrates that the therapy services rendered to the beneficiary were not medically reasonable and necessary)
    • In the Case of Village at Cook Springs (MAC 2012) (The Council modified the ALJ’s decision to clarify that since both the rehabilitative therapy and the nursing services provided to the beneficiaries failed to satisfy the applicable Medicare coverage criteria, no Medicare reimbursement is available for the appellant’s claims associated with those beneficiaries)
    • In the Case of J.A.C. (MAC 2012) (The evidence does not support the conclusion that skilled nursing services were required or received for the enrollee’s condition)
    • In the Case of Estate of B.A. (MAC 2011) (The Council found that the provider, and not the beneficiary, was liable where the provider failed to notify the beneficiary that Medicare would not cover the services furnished)
    • In the Case of Commissioner, Connecticut Department of Social Services (MAC 2011) (an Expedited Determination generic notice by itself provides insufficient notice in a situation where all Medicare-covered services are ending but the provider intends to deliver non-covered care)
    • In the Case of Apple Rehab, Inc. (MAC 2011) (the evidence shows beneficiary became sufficiently dehydrated to require intravenous fluids which is per se skilled nursing service under Medicare regulations)
    • In the Case of Ottawa County Riverview Nursing Home (MAC 2011) (evidence showing the beneficiary went from requiring minimal assistance with activities of daily living to requiring the assistance from two persons for similar functions supports the intervention of skilled rehabilitation services)
    • In the Case of A.L. (MAC 2011) (The beneficiary died after filing a request for hearing before an ALJ. The appellant has not demonstrated that she is authorized to act on behalf of a proper party, or otherwise has any interest as a substitute party)
    • In the Case of Commissioner, State of New Jersey Dept. of Human Services (Whether skilled nursing services are, or are not, medically reasonable and necessary, is a determination that must be made solely on the beneficiary’s unique condition and individual needs, without regard to whether the illness or injury is acute, chronic, terminal or expect to last a long time)
    • In the Case of Twin Maples Health Care Facility (MAC 2010) (Although the physical therapy the beneficiary received at the appellant’s SNF was both skilled and necessary its delivery, alone, does not qualify the SNF for Medicare coverage of the beneficiary’s stay. Medicare coverage is appropriate for the dates of service the beneficiary received skilled nursing services she required and received for her mental health problems)
    • In the Case of Roman Eagle Memorial Home, Inc. (MAC 2010) (the beneficiary is not liable for two stays at the SNF in a noncertified bed as the record reveals the SNF’s notice of Medicare non-coverage to beneficiary’s minor daughter during the first stay was defective and the SNF failed to demonstrate any attempt to obtain a valid consent from the beneficiary during the second stay)
    • In the Case of Connecticut Dept. of Social Services (MAC 2010) (the beneficiary is liable for the non-covered services as the record demonstrates the beneficiary received non-skilled services at the SNF during dates at issue and the SNF gave proper notice of Medicare non-coverage)
    • In the Case of Connecticut Dept. of Social Services (MAC 2008) (the record shows the beneficiary did not possess the requisite capacity to qualify as a capable recipient when he signed the notice of non-coverage)
    • In the Case of Connecticut Dept. of Social Services (MAC 2009) (the medical evidence records the beneficiary’s unstable condition and her need for skilled care and shows the management and evaluations of the beneficiary’s care plan constituted skilled care)
    • In the Case of Elmhurst Care Center (MAC 2009) (certification of the necessity for skilled services on an inpatient basis in a skilled nursing facility may be contained in progress notes, orders, or other documents that have been signed by the physician, not just in a separate form)
    • In the Case of Connecticut Dept. of Social Services (MAC 2009) (the evidence of record shows the beneficiary received intramuscular injections, which constitute skilled nursing services)
    • In the Case of Elmhurst Care Center (MAC 2009) (documentation of the beneficiary’s hospital medication history is required to show which medications the beneficiary had received and to show the medication history was considered for her medical care at the skilled nursing facility)
    • In the Case of Elmwood Health Center (MAC 2009) (the issue of physician certification is not an element of coverage but is a condition for payment)
    • In the Case of Crystal Lake Healthcare and Rehabilitation Center (MAC 2007) (Medicare Part B does not cover separate Part B payment to a skilled nursing facility of routine blood glucose testing under a standing order unless the physician is informed of the results of each test promptly and prior to the performance of the next test and the results are used to manage the beneficiary’s treatment)
    • In the Case of Berkshire Healthcare (MAC 2008) (Medicare coverage is denied as the record fails to show that the physicians were promptly notified of the results of each blood glucose test before the next test was given)
  • Home Health Care
    • In the Case of Delaware Hospice, Inc. (MAC, 2012) (The ALJ erred in waiving appellant’s liability based upon lack of knowledge because the ALJ failed to comply with the language and instructions contained in CMS Ruling 95-1)
    • In the Case of All Valley Home Health (MAC, 2012) (contrary to the ALJ decision, neither attendance at adult day care nor going to doctor’s appointments disqualifies a beneficiary from being homebound)
    • In the Case of Landmark Home Health Care (MAC 2011) (The combination of the beneficiary’s condition, age, medical history and limited mobility created a very reasonable potential for serious complications or a change in condition that could require skilled nursing care)
    • In the Case of R.B. o/b/o J.B. (MAC 2010) (The beneficiary is not homebound as the record indicates she leaves home four days every week to engage in “sheltered workshop” activities (music therapy, games, puzzles, social skills development) at an adult day care center)
    • In the Case of State of Vermont (MAC 2010) (The fact that the beneficiary was at risk for skin breakdown weighs in favor of, rather than against, the need for skilled observation and assessment by a nurse when the beneficiary’s caregivers identified wounds when providing care to the beneficiary)
    • In the Case of Excellent In-Home Care (MAC 2010) (services provided to two beneficiaries were of the nature of general assessments, ongoing observations and repetitive teaching and were not skilled nursing services and therefore not covered by Medicare)
    • In the Case of Landmark Home Health (MAC 2010) (while the evidence of record contains valid plans of care, the services are not covered by Medicare because they were not medically reasonable and necessary)
    • In the Case of G.R.(MAC 2007) (prior appellate determinations finding a beneficiary to be homebound are afforded great evidentiary weight and the record failed to reveal objective medical evidence that his clinical condition had significantly changed for the dates of service at issue)
    • In the Case of Uphams Home Health Care (MAC 2009) (a typewritten name does not meet the signature requirement that home health services based upon a physician’s verbal order be signed and dated with the date of receipt by the registered nurse or other authorized agency recipient)
    • In the Case of New Jersey Dept. of Human Services (MAC 2009) (the totality of circumstances surrounding a beneficiary’s complicated medical condition justifies the physician’s conclusion that she required skilled physical therapy support for maintenance therapy)
    • In the Case of New Jersey Dept. of Human Services (MAC 2009) (although subcutaneous injections are not generally covered home health skilled nursing services, coverage is appropriate in the instant case as the evidence shows the beneficiary was unable to self-inject due to visual impairment and there is no evidence of another person willing and able to administer the injections)
    • In the Case of Prestige Home Care Agency (MAC 2009) (the criteria for coverage for home health skilled nursing services were not met as the evidence fails to show the beneficiaries were likely to have complications or an acute episode that required the observation and assessment by a skilled nurse)
    • In the Case of Rx Home Care, Inc.(MAC 2009) (the home health services provided to the beneficiary did not meet coverage criteria as filling a mediplanner with medications does not require a skilled nurse and the home health agency is liable for the cost of the services as the advance beneficiary notice was signed by the beneficiary more than a year before the dates of service at issue)
    • In the Case of New Jersey Dept. of Human Services (MAC 2009) (the evidence of record as a whole supports coverage of home skilled therapy services as the speech-language therapy was aimed at improving the beneficiary’s dysphagia in swallowing, rather than merely his speaking abilities)
    • In the Case of Visiting Nursing Association of WNY, Inc.(MAC 2009) (although an Outcome and Assessment Information Set (OASIS) form is designed to be a comprehensive patient assessment, the OASIS form should not be the exclusive basis for a determination)
  • Hospice
    • In the Case of Covenant VNA Hospice (MAC 2011) (the medical documentation, overall, indicates a gradual decline in the beneficiary’s condition such that the criteria in Part II and Part III of the applicable LCD were substantially met)
    • In the Case of Solari Hospice Care, LLC (MAC 2011) (the evidence demonstrates the beneficiary had a serious decline in clinical status, before, during, and after the dates of service at issue, and therefore Medicare coverage is appropriate for the hospice services provided by the appellant)
    • In the Case of Continuum Hospice Care (MAC 2009) (the provided hospice services did not meet the certification requirements as the receipt of verbal certification from the attending physician was not documented by either a written or electronic signature by the person purported to receive the verbal certification)
    • In the Case of Innovative Hospice Care (MAC 2009) (while fully favorable determinations for other dates of service do not resolve the coverage issue for the dates of service on appeal, upon review of the applicable local coverage determination, the evidence satisfies the conditions for coverage of hospice services provided to the beneficiary for the dates of service at issue)


  • Skilled Nursing Facilities
    • Partnership to Improve Dementia Care in Nursing Homes (CMS 2014) Antipsychotic drug use in nursing homes trend update.
    • MedPac: Skilled Nursing Facility Services Beneficiaries who need short-term skilled care (nursing or rehabilitation services) on an inpatient basis following a hospital stay of at least three days are eligible to receive covered services in skilled nursing facilities (SNFs) Medicare covers up to 100 days of SNF care per spell of illness. Beginning on day 21 of a SNF stay, a beneficiary is responsible for a daily copayment.
    • Nursing Facilities’ Compliance with Federal Regulations for Reporting Allegations of Abuse or Neglect (OIG 2014) It is estimated that approximately 5 million, or 10 percent, of elderly adults are abused, neglected, or exploited annually. Between now and 2050, the United States is projected to experience significant growth in its elderly population. In 2050, the number of Americans aged 65 and older is projected to be 88.5 million, more than double the population of 40.2 million in 2010.
    • Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring (OIG 2013) Nursing homes hospitalize residents when physicians and nursing staff determine that residents require acute-level care. Such transfers to hospitals provide residents with access to needed acute-care services. However, hospitalizations are costly to Medicare, and research indicates that transfers between settings increase the risk of residents’ experiencing harm and other negative care outcomes. High rates of hospitalizations by individual nursing homes could signal quality problems within those homes.
    • Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OIG 2013) Skilled nursing facilities (SNF) are required to develop a care plan for each beneficiary and provide services in accordance with the care plan, as well as to plan for each beneficiary’s discharge. These requirements are essential to ensuring that beneficiaries receive appropriate care and safely transition from one care setting to another. Several Office of Inspector General studies and investigations found that SNFs had deficiencies in quality of care, did not develop appropriate care plans, and failed to provide adequate care to beneficiaries.
    • Jimmo v. Sebelius Settlement Agreement (CMS 2013) Clarifying that coverage of skilled nursing and skilled therapy services in the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.
    • Manual Medical Review of Therapy Claims Above the $3,700 Threshold (CMS 2014) Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. CMS is not precluded from reviewing therapy services below these thresholds.
    • Therapy Caps and Advance Beneficiary Notice of Noncoverage Fact Sheet (CMS 2013) Provider/supplier must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn’t applicable.
    • Nursing Homes: CMS Needs Milestones and Timelines to Ensure Goals for the Five-Star Quality Rating System Are Met (GAO 2012) In 2008, in an effort to provide helpful information to consumers and improve provider quality, the Centers for Medicare & Medicaid Services (CMS) developed and implemented the Five-Star Quality Rating System (Five-Star System) The Five-Star System assigns each nursing home an overall rating and three component ratings—health inspections, staffing, and quality measures—based on the extent to which the nursing home meets CMS’s quality standards and other measures. The rating scale ranges from one to five stars, with more stars indicating higher quality.
    • Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009 (OIG 2012) SNFs billed one-quarter of all claims in error in 2009, resulting in $1.5 billion in inappropriate Medicare payments. The majority of the claims in error were upcoded; many of these claims were for ultrahigh therapy. The remaining claims in error were downcoded or did not meet Medicare coverage requirements. In addition, SNFs misreported information on the MDS for 47 percent of claims. SNFs commonly misreported therapy, which largely determines the RUG and the amount that Medicare pays the SNF.
    • Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs (OIG 2012) One-third of records reviewed did not contain evidence of compliance with Federal requirements regarding resident assessments, the first step. Further, for 4 percent of records, nursing facility staff did not document consideration of the Resident Assessment Protocol for psychotropic drug use as required, the second step. Ninety-nine percent of records did not contain evidence of compliance with Federal requirements for care plan development, the third step. Finally, 18 percent of records reviewed did not contain evidence to indicate that planned interventions for antipsychotic drug use—the fourth step—actually occurred.
    • Gaps Continue To Exist in Nursing Home Emergency Preparedness and Response During Disasters: 2007-2010 (OIG 2012) Federal regulations for nursing home emergency preparedness require that Medicare and Medicaid certified nursing homes have detailed written plans and procedures to meet all potential emergencies and disasters.
    • Nursing Homes: Private Investment Homes Sometimes Differed from Others in Deficiencies, Staffing, and Financial Performance (GAO 2011) On average, for-profit homes had more total deficiencies than nonprofit homes both before (2003) and after (2009) acquisition. For-profit homes were also more likely to have been cited for a serious deficiency than nonprofit homes before, but not after, acquisition. Serious deficiencies involve actual harm or immediate jeopardy to residents.
    • Nursing Homes: More Reliable Data and Consistent Guidance Would Improve CMS Oversight of State Complaint Investigations (GAO 2011) In part because of data reliability concerns, CMS does not routinely use data from the complaints database to calculate certain measures that could enhance its understanding of agencies’ performance. Although CMS requires state survey agencies that fail performance standards to develop corrective action plans, states’ plans do not necessarily address the underlying causes of performance issues, such as staffing shortages.
    • Payments for Medicare Part B Services During Non-Part A Nursing Home Stays in 2008 (OIG 2011) We found that Medicare paid $4.9 billion for Part B services during non-Part A stays in 2008. Three service categories, therapy services, evaluation and management, and major and minor medical procedures, made up 58 percent of the total payment. In addition, Part B services were rendered in a variety of places, with 54 percent of payments for services rendered inside nursing homes and 46 percent of payments for services rendered outside of nursing homes (e.g., outpatient hospitals and physician offices).
    • Changes in Skilled Nursing Facilities Billing in Fiscal Year 2011 (OIG 2011) OIG found that Medicare payments to SNFs increased from 2006 to 2008, even though beneficiary characteristics remained largely unchanged. Specifically, payments to SNFs for the highest level of therapy increased by nearly 90 percent from 2006 to 2008, rising from $5.7 billion to $10.7 billion. Billing for high levels of assistance with ADLs also increased.
    • Nursing Facilities’ Employment of Individuals With Criminal Convictions (OIG 2011) Federal regulation prohibits Medicare and Medicaid nursing facilities from employing individuals found guilty of abusing, neglecting, or mistreating residents by a court of law, or who have had a finding entered into the State nurse aide registry concerning abuse, neglect, or mistreatment of residents or misappropriation of their property.
    • Questionable Billing by Skilled Nursing Facilities (OIG 2010) Medicare pays SNFs under a prospective payment system. Under this system, SNFs classify each beneficiary into a group based on his or her care and resource needs. These groups are called resource utilization groups (RUGs), and each RUG has a different Medicare per diem payment rate. Medicare classifies RUGs into eight distinct categories. Two of the categories are for beneficiaries who need therapy. The remaining six categories are for beneficiaries who require very little or no therapy. Medicare payment rates are generally higher for therapy RUGs than for nontherapy RUGs.
    • Nursing Homes: Opportunities Exist to Facilitate the Use of the Temporary Management Sanction (GAO 2009) The nation’s 1.4 million nursing home residents are a highly vulnerable population of elderly and disabled individuals for whom remaining at home is no longer feasible. According to CMS guidance, temporary management may be used instead of termination in cases where nursing homes place residents at risk of death or serious injury–referred to as immediate jeopardy–or place residents at widespread risk of actual harm.
    • Nursing Homes: CMS’s Special Focus Facility Methodology Should Better Target the Most Poorly Performing Homes, Which Tended to Be Chain Affiliated and For-Profit (GAO 2009) According to GAO’s estimate, almost 4 percent (580) of the roughly 16,000 nursing homes in the United States could be considered the most poorly performing. GAO found that the most poorly performing nursing homes had notably more deficiencies with the potential for more than minimal harm or higher and more revisits than all other nursing homes. For example, the most poorly performing nursing homes averaged about 56 such deficiencies and 2 revisits, compared to about 20 such deficiencies and less than 1 revisit for all other homes. In addition, the most poorly performing homes tended to be chain affiliated and for-profit and have more beds and residents.
    • Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents (GAO 2007) GAO (1) analyzed federal sanctions from fiscal years 2000 through 2005 against 63 homes previously reviewed and (2) assessed CMS’s overall management of enforcement. The 63 homes had a history of harming residents and were located in 4 states that account for about 22 percent of homes nationwide.
    • Nursing Homes: More Can Be Done to Protect Residents from Abuse
      (GAO 2002) No federal statute requires criminal background checks for nursing home employees. Background checks are also not required by the Centers for Medicare and Medicaid Services, which sets the standards that nursing homes must meet to participate in the Medicare and Medicaid programs. Although state agencies compile lists of aids who have previously abused residents, which can prevent an aide from being hired at another nursing home, GAO found that delays in making these identifications can limit the usefulness of these registries.

    • Nursing Homes: Too Early to Assess New Efforts to Control Fraud and Abuse (GAO 1997) GAO discussed the challenges that exist in combatting fraud and abuse in the nursing facility environment.
    • Skilled Nursing Facilities: Approval Process for Certain Services May Result in Higher Medicare Costs (GAO 1996) Pursuant to a congressional request, GAO reviewed: (1) the growth of skilled nursing facility (SNF) costs and SNF use in relation to hospital use.
    • Early Resolution of Overcharges for Therapy in Nursing Homes is Unlikely (GAO 1996) Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration’s (HCFA) progress in curbing overbilling for occupational speech and physical therapy services.
    • Fraud and Abuse: Providers Target Medicare Patients in Nursing Facilities (GAO 1996) Pursuant to a congressional request, GAO reviewed allegations of fraud and abuse related to services and supplies provided to nursing facility patients.
    • Tighter Rules Needed to Curtail Overcharges for Therapy in Nursing Homes (GAO 1995) Nursing homes and rehabilitation centers are taking advantage of ambiguous payment rules and lack of guidelines to bill Medicare at inflated rates for therapy services.
  • Home Health/Assisted Living
    • MedPac: Home Health Care Services Payment System Beneficiaries who are generally restricted to their homes and need skilled care (from a nurse, physical or speech therapist) on a part-time or intermittent basis are eligible to receive certain medical services at home. Home health agency (HHA) personnel visit beneficiaries’ homes to provide services. Originally the benefit had more restrictive coverage standards, such as requiring a prior hospital stay or limiting the number of visits allowed. These limitations were eliminated, and a beneficiary can receive an unlimited number of episodes as long as they meet the other coverage criteria.
    • Limited Compliance With Medicare’s Home Health Face to Face Requirements (OIG 2014) For 32 percent of home health claims that required face-to-face encounters, the documentation did not meet Medicare requirements, resulting in $2 billion in payments that should not have been made. Furthermore, physicians inconsistently completed the narrative portion of the face-to-face documentation. podcast
    • State Requirements for Conducting Background Checks on Home Health Agency Employees (OIG 2014) The survey found that, of the 50 States and the District of Columbia (hereinafter referred to as States), 41 States require HHAs to conduct background checks on prospective employees. Ofthe 10 States that have no background-check requirement, 4 States reported that they have plans to implement background-check requirements in the future. Of the 41 States that require background checks, 15 States require HHAs to receive the results of background checks before individuals can begin employment and 26 States allow individuals to work while the results of their background checks are pending.
    • Home Health Agencies Received Timely Surveys and Corrected Deficiencies As Required (OIG 2013) Over the last decade, the use of home health services increased significantly and Medicare payments to home health agencies (HHA) more than doubled. To ensure that HHAs comply with Federal requirements, the Centers for Medicare & Medicaid Services (CMS) contracts with each State survey agency (State agency) and three accreditation organizations to conduct initial certification surveys of HHAs, recertification surveys, and complaint investigations.
    • Limited Oversight of Home Health Agency OASIS Data (OIG 2012) HHAs did not meet all Federal reporting requirements. They did not submit required OASIS data for 392,180 (6 percent) of claims in 2009, which represented over $1 billion in Medicare payments. Only 199 HHAs were penalized by CMS with the 2-percent payment reduction from 2007 through 2010.
    • Criminal Convictions for Nurse Aides With Substantiated Findings of Abuse, Neglect, and Misappropriation (OIG 2012) The objective of this memorandum report is to provide baseline information for the mandated report on the extent to which nurse aides with substantiated findings of abuse, neglect, and/or misappropriation had previous criminal convictions that could have been detected through background checks and the nature of those convictions.
    • Home and Community-Based Services in Assisted Living Facilities (OIG 2012) We selected the 7 States with the highest numbers of beneficiaries receiving these services in ALFs: Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas, and Washington. Using claims data from these 7 States, we selected a random sample of 150 beneficiaries. To determine the extent to which Medicaid programs complied with Federal and State requirements for HCBS furnished under the waiver, we reviewed State survey agency inspection reports for ALFs in which beneficiaries from our sample resided. We also reviewed plans of care associated with the sampled beneficiaries.
    • Assisted Living: Examples of State Efforts to Improve Consumer Protections (GAO 2004) Assisted living facilities provide help with activities of daily living (ADL) in a residential setting for individuals who do not require 24-hour skilled nursing care. In 2002, over 36,000 assisted living facilities served approximately 900,000 residents. In contrast to nursing homes, with their extensive federal rules and mandates, the federal government exercises minimal oversight of assisted living facilities. The states establish and enforce licensing standards for these institutions.
    • Assisted Living: Quality-of-Care and Consumer Protection Issues in Four States (GAO 1999) We studied four states that have a range of experiences with assisted living—California, Florida, Ohio, and Oregon. Specifically, we (1) analyzed responses to a mail survey from 622 assisted living facilities concerning the services they provide and the needs of the residents they serve; (2) evaluated written marketing materials and contracts of 60 facilities for completeness, clarity, and consistency with selected state statutes and regulations; (3) interviewed state officials in the four states and reviewed relevant state statutes, regulations, guidance, and policy manuals; and (4) analyzed information on the quality-of-care and consumer protection problems identified by the state licensing and ombudsmen agencies in each state.
    • Long-Term Care: Consumer Protection and Quality-of-Care Issues in Assisted Living (GAO 1997) Pursuant to congressional request, GAO reviewed assisted living facilities (ALF), focusing on: (1) responsibilities of federal and state governments and ALFs in ensuring quality and protecting consumers living in ALFs; and (2) issues that may require further research.
    • Home Health Benefit:
      Congressional and HCFA Actions Begin to Address Chronic Oversight Weaknesses
      . (GAO 1998) This testimony summarizes (1) the general nature of beneficiary eligibility criteria, which opportunists exploit to provide excessive services; (2) diminished Medicare contractor review and audit effort, which makes it less likely that abusers will be caught; (3) weaknesses in Medicare’s home health provider certification process; and (4) new tools that Congress has provided to strengthen oversight of the home health benefit.

    • Improper Activities by Mid-Delta Home Health. (GAO 1998) Discusses the results of its investigation into allegations of improper Medicare billings by Mid-Delta Home Health.
    • Home Health
      Agencies: Certification Process Ineffective in Excluding Problem Agencies.
      (GAO 1997) Reviews how the Health Care Financing Administration (HCFA): (1) controls the entry of home health agencies (HHA) into the Medicare program; (2) ensures that certified HHAs continue to comply with Medicare’s conditions of participation and associated standards; and (3) decertifies HHAs that are not complying with Medicare’s requirements.

    • Home Health:
      Differences in Service Use by HMO and Fee-for-Service Providers.
      (GAO 1997) Information on home health
      services provided by Medicare health maintenance organizations (HMO), focusing on: (1) how Medicare HMOs provide and manage home health services, as compared to fee-for-service providers; and (2) what is known about the appropriateness of home health services provided to HMO enrollees, especially to vulnerable populations.

    • Home Health:
      Success of Balanced Budget Act Cost Controls Depends on Effective and Timely Implementation.
      (GAO 1997) Examines how the Balanced Budget Act of 1997 has addressed rapid cost growth in Medicare’s home health benefit.

    • Need to Hold Home
      Health Agencies More Accountable for Inappropriate Billings
      (GAO 1997) Pursuant to a congressional request, GAO reviewed Medicare’s ability to detect and prevent inappropriate payments to home health agencies.

    • Consumer Protection and Quality-of-Care Issues in Assisted Living (GAO 1997) Pursuant to congressional request, GAO reviewed assisted living facilities (ALF), focusing on: (1) responsibilities of federal and state governments and ALFs in ensuring quality and protecting consumers living in ALFs; and (2) issues that may require further research.
    • Home Health Cost
      Growth and Administration’s Proposal for Prospective Payment
      (GAO 1997) GAO discussed Medicare’s home health care benefit and the administration’s forthcoming legislative proposals related to this Medicare benefit.

    • Home Health and Skilled Nursing Facility Cost Growth and Proposals for Prospective Payment (GAO 1997) GAO discussed Medicare’s skilled nursing facility (SNF) and home health care benefits and the administration’s forthcoming legislative proposals related to them.
    • How Continuing Care Retirement Communities Manage Services for the Elderly (GAO 1997) Pursuant to a congressional request, GAO reviewed the processes of managed care in continuing care retirement communities (CCRC), focusing on: (1) CCRC practices for promoting wellness; (2) practices for managing care for elderly people with chronic conditions; and (3) evidence regarding the possible effect of these practices on health status and costs.
    • Some States Apply Criminal Background Checks to Home Care Workers (GAO 1996) Persons needing assistance with daily activities generally prefer home- and community-based services to nursing homes, and increasing numbers of elderly and disabled persons are turning to paid home care workers for such services.
    • Medicare: Home
      Health Utilization Expands While Program Controls Deteriorate
      (GAO 1996) Pursuant to a congressional request, GAO examined the growth in the use of Medicare home health benefits.

    • Allegations Against ABC Home Health Care (GAO 1995) In response to a congressional request, GAO investigated allegations against ABC Home Health Care, a home health agency (HHA), and its participation in the Medicare home health care

    • Status of Quality Assurance and Measurement in Home and Community-Based Services (GAO 1994) This report examines how quality is ensured and measured in home and community-based long-term care services for elderly persons with disabilities.
  • Hospice
    • Medicare Hospices Have Financial Incentives To Provide Care In Assisted Living Facilities (OIG 2015) Medicare payments for hospice care in ALFs more than doubled in 5 years, totaling
      $2.1 billion in 2012. Hospices provided care much longer and received much higher Medicare payments for beneficiaries in ALFs than for beneficiaries in other settings. podcast

    • MedPac: Hospice Services Payment System The Medicare hospice benefit covers a broad set of palliative services for beneficiaries who have a life expectancy of six months or less, as determined by their physician. Beneficiaries who elect the Medicare hospice benefit agree to forgo curative treatment for their terminal condition. For conditions unrelated to their terminal illness, Medicare continues to cover items and services outside of hospice. Typically, hospice care is provided in patients’ homes, but hospice services may also be provided in nursing facilities and other inpatient settings.
    • Medicare Hospice: Use of General Inpatient Care (OIG 2013) Hospice general inpatient care (GIP) is for pain control or symptom management provided in an inpatient facility that cannot be managed in other settings. The care is intended to be short-term and is the second most expensive level of hospice care.
    • Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OIG 2013) We found that the frequency of recertification surveys had not improved since 2005. As of the index date of February 28, 2013, 17 percent of State-surveyed hospices had not been recertified within the preceding 6 years, with some hospices experiencing longer intervals since their most recent survey.
    • Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements (OIG 2009) The Medicare hospice benefit allows a beneficiary with a terminal illness to forgo curative treatment for the illness and instead receive palliative care. The number of beneficiaries receiving hospice care has increased significantly in recent years, and some studies suggest that the use of hospice care has grown most rapidly in nursing facilities.
    • Medicare Hospice Care: Services Provided to Beneficiaries Residing in Nursing Facilities (OIG 2009) In this evaluation, we found that 31 percent of Medicare hospice beneficiaries resided in nursing facilities in 2006. Medicare paid $2.59 billion for their hospice care, at an average of $960 per week for each hospice beneficiary residing in a nursing facility. Hospices most commonly provided nursing, home health aide, and medical social services. They furnished an average of 4.2 visits per week for these three services combined. They also commonly provided drugs.
    • Hospice Beneficiaries’ Use of Respite Care (OIG 2008)
      We found that 2 percent of all hospice beneficiaries received respite care during 2005. Most of these beneficiaries received respite care for a total of 5 days or less. We also found a number of instances in which the use of respite care may have been inappropriate. Fifty-four beneficiaries received respite care longer than the 5 consecutive days allowed by Federal regulations and 62 beneficiaries received respite care while residing in nursing facilities, contrary to Federal requirements.

    • Medicare Hospice Care: A Comparison of Beneficiaries in Nursing Facilities and Beneficiaries in Other Settings (OIG 2007) This study describes the characteristics of Medicare hospice beneficiaries who resided in nursing facilities in 2005 and compares this population to Medicare hospice beneficiaries who resided in other settings.
    • Medicare Hospices: Certification and Centers for Medicare & Medicaid Services Oversight (OIG 2007) Eighty-six percent of hospices were certified within 6 years, as required, while 14 percent averaged 3 years past due. Hospices that were 3 years past due for certification had not been surveyed for
      9 years—3 years longer than the CMS standard at the time of our review.

    • More Beneficiaries Use Hospice; Many Factors Contribute to Shorter Periods of Use (GAO 2000) GAO discussed issues related to the use of Medicare’s hospice benefit, focusing on: (1) the patterns and trends in hospice use by Medicare beneficiaries; (2) factors that affect the use of the hospice benefit; and (3) the availability of hospice providers.
    • Fraud and Abuse In Nursing Home Arrangements with Hospices (OIG 1998) Focuses on the interrelationship between the hospice and nursing home industries and describes some potentially illegal practices the OIG has identified in arrangements between these providers.
    • Medicare Hospice Beneficiaries: Services and Eligibility (OIG 1998) Hospice services are intended to provide comfort and relief from pain, as opposed to curative care. To elect hospice care under Medicare, a beneficiary must be eligible for Part A Medicare. Beneficiaries must also be certified by a physician as being terminally ill, with a life expectancy of 6 months or less if an illness runs its normal course.
    • Hospice and Nursing Home Contractual Relationships (OIG 1997) For nursing home patients who are dually entitled to Medicare and Medicaid and who choose the hospice benefit, Medicaid pays the hospice for the patient’s room and board, (no less than 95 percent of the Medicaid daily rate), and Medicare pays the hospice for the hospice benefit. The hospice then pays the nursing home for daily care, and, depending on the arrangement made between the hospice and the nursing home, for other services as well.
    • Hospice Patients in Nursing Homes (OIG 1997) Nursing home hospice patients received nearly 46 percent fewer nursing and aide services from hospice staff than hospice patients living at home. Three out of four patients received only basic nursing and aide visits. Many of these services were also provided by the nursing home staff when hospice staff were not present. Yet, hospices get paid the same amount for nursing home patients as they receive for patients living at home.
  • Other


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