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One in five high-risk ER Medicare claims is the result of abuse or neglect


What Office of Inspector General Found

OIG determined that an estimated one in five high-risk hospital ER Medicare claims for treatment provided in calendar year 2016 were the result of potential abuse or neglect, including injury of unknown source, of beneficiaries residing in a SNF. OIG determined that CMS does not require all incidents of potential abuse or neglect and related referrals made to law enforcement and other agencies to be recorded and tracked in the Automated Survey Processing Environment Complaints/Incidents Tracking System. Preventing, detecting, and combating elder abuse requires CMS, Survey Agencies, and SNFs to meet their responsibilities.


The majority of Medicare beneficiaries admitted to skilled nursing facilities (SNFs) are elderly. Elder abuse and neglect is a serious problem, with the elderly population expected to reach approximately 84 million by 2050.1 In 2008, 1 in 10 elderly persons reported emotional, physical, or sexual abuse or potential neglect in the previous year.


OIG review covered 37,607 high-risk hospital ER Medicare claims nation-wide,14 which involved 34,820 of the approximate 1.9 million beneficiaries residing in SNFs during calendar year 2016. The beneficiaries associated with these claims were transported to the ER directly from a SNF during 2016. These claims were 27,127 hospital outpatient and 10,480 inpatient claims, totaling $163,207,281, and contained at least 1 of 580 diagnosis codes consisting of outpatient principal diagnosis codes and inpatient admitting diagnosis codes that were determined to be high risk for potential abuse or neglect. The 580 diagnosis codes included head injuries, bodily injuries, and safety and medical issues. OIG selected these codes to identify incidents of potential abuse or neglect that were not specifically coded by the treating medical providers on the associated Medicare claim as involving potential abuse or neglect.


OIG determined that an estimated one in five high-risk hospital ER Medicare claims for treatment provided in calendar year 2016 were the result of potential abuse or neglect, including injury of unknown source, of beneficiaries residing in a SNF. They determined that SNFs failed to report many of these incidents to the Survey Agencies in accordance with applicable Federal requirements. It was also determined that several Survey Agencies failed to report some findings of substantiated abuse to local law enforcement.


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Source: https://oig.hhs.gov/oas/reports/region1/11600509.pdf

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