OIG Nursing Facility Compliance Program Recent Guidance: Medicare and Medicaid Billing Requirements

Nursing facilities: Are you monitoring Medicare and Medicaid billing requirements as part of your compliance and ethics programs?

On November 20, 2024, the Department of Health and Human Services Office of Inspector General (OIG) published an updated Industry Segment-Specific Compliance Program Guidance document for nursing facilities (Nursing Facility ICPG). OIG tailored the Nursing Facility ICPG to risk areas specific to the nursing facility industry segment and recommended compliance measures that facility operators can take to reduce those risks.

This article will focus specifically on OIG’s discussion of Medicare and Medicaid billing risks and its recommendations to mitigate such risks. In a previous article, we reviewed why nursing facilities must prioritize—as well as best practices from the OIG related to risk areas within—quality of care and quality of life for residents.

Why should compliance and ethics programs focus on Medicare and Medicaid billing requirements?

Nursing facilities should ensure compliance with Medicare and Medicaid billing requirements because failing to do so can result in submitting, or causing submission of, false claims. Submitting a false claim or causing a false claim to be submitted to a federal healthcare program may subject an individual and/or an entity to criminal prosecution, civil liability under the False Claims Act (FCA) or Civil Monetary Penalties Law, and exclusion from participating in federal healthcare programs. Nursing facilities must take proactive measures to ensure compliance with program rules, including conducting regular reviews to ensure billing and coding practices are current and accurate and performing regular internal billing and coding audits. If an entity detects a coding error, it must return the overpayment to the government to avoid FCA liability.

In the Medicare and Medicaid Billing Requirements section of the Nursing Facility ICPG, OIG discusses billing risk areas and recommendations to mitigate those risks. Specifically, OIG highlights:

1. Skilled Nursing Facility (SNF) Prospective Payment System (PPS);
2. Value-based payment models and programs;
3. Medicare Advantage and Medicaid managed care;
4. Medicare Part D; and
5. Medicare health plan enrollment for nursing facility residents.