Nursing Home Enforcement: Processing Denials of Payment



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Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
Daniel R. Levinson Inspector General

May 2008
OEI-06-03-00390

N
URSING HOME
E
NFORCEMENT
:
P
ROCESSING DENIALS OF MEDICARE
P
AYMENT




Office of Inspector General http://oig.hhs.gov
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components Office of Audit Services The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation and Inspections The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations. Office of Investigations The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. Office of Counsel to the Inspector General The Office of Counsel to the Inspector General (OCIG) provides general legal services to
OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities.




E xe cut ives um mary b objective
During fy 2004, 74 percent of denial of payment remedies were
U rsi n g h
Manage dpna cases to ensure that all dpna instructions are sent
R o ce ss ing
A ck now led gm en ts
Denial of payment remedies
Processing denial of payment remedies
Sample selection
Data collection and analysis
O e i - 0 6 - 0 3 - 0 0 3 9 0 n
Table 1: cms and fi processing of medicare dpna cases in fy 2004
Manage dpna cases to ensure that all dpna instructions are sent
Address communication breakdowns by implementing a standard
Update and clarify guidance on coding readmissions and verifying
Agency comments and office of inspector general


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