Across the country, crimes involving elder abuse and elder neglect routinely go unreported. But even when those cases are not immediately reported to police, there can often be clues in Medicare and Medicaid data. The Centers for Medicare and Medicaid Services (CMS) already looks for those signs in claims data. But a recent IG audit found a lot more cases that could have been reported to state and local authorities if CMS had done a more rigorous analysis. Curtis Roy is a regional inspector general with the Health and Human Services IG’s office. Richard Miller is an assistant regional inspector general. They talked with Federal News Network’s Jared Serbu about their findings, on the Federal Drive with Tom Temin. Miller speaks first.

Interview Transcript: 

Richard Miller Promoting public health and safety is a major component of the HHS OIG strategic plan. And we’ve conducted a number of audits in different care settings that reveal problems related to unreported incidents of potential abuse and neglect. Our current work really started about a decade ago after several media reports concerning unreported abuse and neglect in group homes. At that time, the challenge we faced was how to identify incidents that we’re not aware of that aren’t reported. That’s when we came up with the idea to focus on data analysis. If the patients require medical treatment and Medicare pays for it, then there is a record of the events, even if it was unreported. And that was really our starting point. This type of data analysis wasn’t being performed at the time. It was about thinking outside the box to help address an ongoing problem.   

Jared Serbu That makes perfect sense, and that’s a great setup to talk about what you actually found in this in this latest audit. So tell us a bit about what the numbers reveal about the total number of potentially unreported cases out there.   

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Richard Miller So by performing a data extract of Medicare claims data using these diagnosis codes that specifically indicate abuse and neglect was suspected. We identified approximately 30,000 claims over a two year period where abuse or neglect was suspected. We then selected a random sample of these claims, reviewed the supporting medical records and confirm whether the incidents were reported to the appropriate agencies. We found that as many as 1 in 5 of the incidents weren’t properly reported. If the agency is unaware of the incident, then they can’t investigate, ensure that the Medicare enrollees are safe in receiving the quality care they deserve.   

Jared Serbu And is CMS correctly identifying any universe of these potential cases and notifying law enforcement? How does that currently work? How is it? How? How could it work?   

Richard Miller Sure. CMC shares the same commitment to patient safety as the HHS OIG. And is well aware that abuse neglect of Medicare enrollees is a significant problem. In fact, there are federal requirements such as the conditions of participation and 1150 section 1150-B of the Social Security Act that specifically address reporting cases of abuse and neglect. However, based on the results of our audit, we’re seeing that there are gaps in these requirements. The recommendations in our report were for CMS to analyze the data to identify specific trends and patterns, conduct our targeted claims review to assess the issue, and develop guidance in best practices based on their findings. We also recommended that CMS assess whether existing federal requirements for reporting abuse and neglect should be strengthened, and CMS did agree with all of our recommendations. The key takeaway from this audit is that Medicare data is a valuable resource and there’s a real opportunity to use this data to protect Medicare enrollees by reducing the frequency of unreported incidents. So we’ve conducted a number of related audits which really started with Medicaid data. And based on the results of those audits, we have clear evidence that this type of data analysis does work. Based on our prior work, we’re starting to see states effectively use data analysis to reduce unreported incidents in the Medicaid program. And we’re confident that a similar approach can benefit Medicare enrollees as well.   

Jared Serbu And this may be beyond the scope of your work, but is there any sense at this point how big a lift it would be for CMS to start using the data in the way that you’re suggesting? Or do they have the adequate analytical capability to start making this routine?   

Richard Miller Sure. CMS does have current safeguards in place for the air quality improvement and program integrity functions to improve quality of care and prevent fraud, waste and abuse. I just want to make it clear that there are current mechanisms in place in our recommendations are intended to improve those mechanisms. A few years ago, we issued a related audit report where we recommended that CMS perform a similar type of. Claims analysis and then provide that data to the states so the states can ensure that the incidents were properly reported. However, as part of our current audit, we met with CMS to really understand the obstacles that they had implemented our prior recommendations. You know, it’s been a number of years and the recommendations still haven’t been implemented. Based on these conversations, we came to understand that there’s a better mechanism to perform this function. We specifically recommended in our report for CMS to analyze the trends. Assess the issue, and then decide where to go from there.   

Jared Serbu So the main obstacle. Can you explain a little bit more why was reporting back to the states the recommendations that you made in your previous audit work, the recommendation that they communicate directly with the states? Why did they see that as an obstacle? And why is the approach you’re now recommending? Seen as more feasible?   

Richard Miller So in our prior order report, CMS did not concur with several of our recommendations. They cited several issues with providing the data to the states, such as logistical issues as well as concerns with HIPAA provisions.   

Jared Serbu Okay. So this new approach essentially just gives them a little bit more freedom to make good decisions about what to do with that data rather than setting a strict policy that says this information goes to the states. If I got that about right.   

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Richard Miller So that that’s exactly right. Our recommendations are intended to give CMS the flexibility to use their expertise and then to develop methods to incorporate the data analysis methodology that we developed.   

Jared Serbu And Kurt, I definitely want to get you in here before we have to say goodbye. You know, what else should people know about this audit and any other resources out there that you might want to mention?   

Curtis Roy Yeah. You know, we view this as a problem. We’ve done multiple reports on this issue. And one of the things that I always like to say to folks who, you know, have relatives in some sort of care facility, be it a nursing home, skilled nursing facility, group home, whatever it might be, a hospital, wherever, that if people see something that they question whether or not potential abuse or neglect is occurring, that they say something. Because again, this is all part of that getting these possible incidents reported in to the proper authorities so that they can be checked out. And if something’s wrong, it can be dealt with. Because if people don’t say anything, it may take a while for the things that we’re recommending to loop back around and, you know, get that data back out to the people that can do something about it. We wrote back in 2019 a resource guide that’s out on our website. In order to help our partners out there do the kind of data analysis that we’re talking about right here, whether they be a Medicare contractor who processes these insurance claims, whether it’s a compliance department in a hospital or whether it’s a state Medicaid agency. You know, and we’ve heard from all of these different types of groups about this resource guide. It is being used and it’s just a step by step how to volume to show people what was the logic that we used when we started doing this kind of data analysis. Written in such a fashion that they can follow it too, and that they can do what we’ve done. Resource Guide for Using Diagnosis Codes in Health insurance claims to help identify unreported abuse or neglect. It is pretty useful and it does address an awful lot about what we’ve just talked about.   

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