CMS Can Do More To Leverage Medicare Claims Data To Identify Unreported Incidents of Potential Abuse or Neglect

Why OIG Did This Audit

We previously conducted an audit of CMS's use of Medicare data to identify incidents of potential abuse or neglect and found that CMS did not use Medicare claims data to identify incidents of abuse or neglect of Medicare enrollees. CMS did not concur with three of our four prior audit recommendations.

Our objectives were to determine: (1) the prevalence of incidents of potential abuse or neglect of Medicare enrollees for 2019 and 2020, (2) who may have perpetrated those incidents and where they occurred, and (3) whether the incidents were reported to law enforcement.

How OIG Did This Audit

Our audit covered claims from January 2019 through December 2020 for services provided to treat Medicare enrollees with diagnosis codes related to abuse or neglect. We sampled 100 Medicare claims and reviewed the medical records to determine whether they contained evidence of potential abuse or neglect, who perpetrated those incidents, where they occurred, and whether law enforcement was alerted. We also discussed with CMS the reasons for its nonconcurrence with our prior recommendations.

What OIG Found

We identified 30,258 Medicare claims for services provided from January 1, 2019, through December 31, 2020, that contained diagnosis codes indicating the treatment of injuries potentially caused by abuse or neglect of Medicare enrollees. Of the 100 Medicare claims we sampled, 93 had medical records that contained evidence of potential abuse or neglect. We also determined that of these 93 claims, 14 were allegedly perpetrated by health care workers, 17 were related to incidents that occurred in medical facilities, and 18 were related to incidents that were not reported to law enforcement. On the basis of our sample results, we estimated that 27,522 of the 30,258 Medicare claims we identified from 2019 and 2020 were supported by medical records that contained evidence of potential abuse or neglect. We further estimated that, of the claims in our sampling frame associated with incidents of potential abuse or neglect, 2,320 were allegedly perpetrated by health care workers, 3,546 were related to incidents that occurred in medical facilities, and 7,298 were related to incidents that were not reported to law enforcement.

What OIG Recommends and CMS Comments

We recommend that CMS: (1) conduct data analyses to identify trends and high-risk areas in Medicare claims containing diagnosis codes indicating potential abuse or neglect; (2) provide the results of the analyses to Quality Improvement Organizations and Medicare Program Integrity contractors so that they can conduct targeted claim reviews to identify patterns of unreported incidents of potential abuse or neglect and the reasons the incidents were unreported; (3) based on the results of the targeted claim reviews, develop and share guidance and best practices with providers to help ensure that incidents are reported in compliance with State mandatory reporting laws; and (4) consider the results of targeted claims reviews when assessing whether the existing conditions of participation requirements for reporting abuse or neglect of Medicare enrollees should be strengthened.

CMS concurred with our recommendations and described actions it plans to take to address most of them. For example, CMS stated that it will develop and share guidance with providers on reporting instances of potential abuse or neglect. CMS also stated that it will evaluate all available evidence as it pertains to abuse and neglect when assessing the need for revisions to the existing conditions of participation.