By examining the reports, audits, and investigations listed, facilities can gain valuable insights into common compliance risks, such as improper denials, payment errors, and marketing violations, that directly impact resident care and facility reimbursement. This knowledge empowers skilled nursing facilities to proactively strengthen their compliance programs, engage in informed contract negotiations with MA plans, and advocate for fair and transparent utilization review practices that prioritize resident needs.
The growth of managed care over the last several years has changed fundamental aspects of the Medicare and Medicaid programs. This significant shift transformed how the government pays for and covers health care for approximately 100 million enrollees.
The OIG has designated oversight of managed care as a priority area. OIG has developed a strategy to align its audits, evaluations, investigations, and enforcement of managed care. The HHS-OIG Strategic Plan for Oversight of Managed Care for Medicare and Medicaid has three goals:
Resources available include:
HHS-OIG. (2024, January 9). Managed Care | HHS-OIG. https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/index.asp
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
