The Department of Health & Human Services (HHS) Office of the Inspector General (OIG) released a report on November 7 related to the use of Medicare claims data to identify potential abuse and neglect. This report follows up on a 2019 report and modifies recommendations for actions the Centers for Medicare & Medicaid Services (CMS) can take. The audit examined 100 Medicare claims filed in 2019 and 2020 with diagnosis codes that potentially indicated abuse and neglect. Based on the findings of the sample, OIG estimated that approximately 7% of potential abuse and neglect was perpetrated by health care workers, approximately 11% occurred in health care settings, and approximately 24% of these potential incidents of abuse and neglect were not reported according to state and federal requirements.

OIG recommended that CMS utilize this data to identify high-risk areas and trends, share the information with the Quality Improvement Organizations for more targeted review and assistance, and review abuse and neglect regulations and sub-regulatory guidance for areas for improvement. CMS accepted the recommendations without committing to the specific actions OIG  outlined.

LeadingAge will keep an eye on this work. While the report focuses broadly on claims filed on behalf of all Medicare beneficiaries—not solely those residing in nursing homes or other health care settings—it has the potential to impact policies in CMS-certified settings, for instance in how abuse and neglect is identified, reported, and surveyed.