Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

N H E :

URSING  OME  NFORCEMENT
C C M
OLLECTION OF  IVIL  ONEY 

P
ENALTIES

Daniel R. Levinson 

Inspector General 

July 2005

OEI-06-03-00420
 Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs. This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 
and program evaluations (called inspections) that focus on issues of concern to the 
Department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. The OI also oversees 
state Medicaid fraud control units, which investigate and prosecute fraud and patient 
abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations. The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department. The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidelines, renders advisory opinions on OIG sanctions to 
the health care community, and issues fraud alerts and other industry guidance. 
`    E X E C U T I V E   S U M M A R Y

OBJECTIVE 
To determine the extent to which the Centers for Medicare & Medicaid 
Services (CMS) collected civil money penalties (CMPs) and took required 
collection actions for nursing home enforcement cases initiated in 
calendar year (CY) 2002. 
BACKGROUND 
CMPs are fines that CMS can impose on Medicare- and Medicaid-certified 
nursing facilities that are found to be noncompliant with Federal safety 
and quality of care standards.  CMS is charged with ensuring that 
facilities pay their fines and is required by Federal law, regulations, and 
policies to take specified collection actions. Delays in collections, or lack 
of collections, have the potential to undermine the CMPs intended effect 
of ensuring that facilities promptly return to compliance. 
Required collection actions include providing facilities with complete 
notification that the CMP is due, assessing interest on unpaid balances, 
referring past-due CMPs to fiscal intermediaries and State Medicaid 
agencies to be offset from funds owed to facilities, and transferring debt 
over 180 days past due to the Department of the Treasury. 
We examined case information obtained from CMS to determine whether 
each of the CMPs initiated in CY 2002 were collected in full, partially 
collected, or remained uncollected as of March 2004. We also assessed 
timeliness of collections.  Through analysis of documentary evidence we 
determined the extent to which CMS took all required actions to collect 
the 228 CMPs that became past due by more than 30 days.  Information 
obtained from interviews with CMS staff in the central office and each of 
the 10 regional offices provided additional information about collection 
procedures. 
FINDINGS 
As of March 2004, CMS did not fully collect 4 percent of the CMPs 
imposed in CY 2002 and collected another 8 percent well after the due 
dates.  We found that 12 percent (228 out of 1,938) of collectable CMPs 
initiated in CY 2002 became past due by more than 30 days.  CMS had 
not fully collected 79 CMPs (4 percent of the total) by March 2004, the end 
of our study period.  Further, the collection that did occur (149 collected 
cases) was often very late, with an average collection time of 115 days 
past the due date.   
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  i  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY
Forty-four CMPs had no collections during this time period. Of these 
CMPs, 31 were for facilities that were found to be out of compliance in an 
inspection following the one that resulted in the imposition of the CMP. 
CMS did not take all required actions to collect 94 percent of past-
due CMPs, but took some actions beyond those required that 
improved collection results. For 40 percent of past-due CMPs, CMS 
failed to provide complete notification with all required information, 
including when the CMPs were due. CMS did not assess interest on 72 
percent of the past-due CMPs as required and did not refer 71 percent 
of past-due CMPs to fiscal intermediaries and State Medicaid agencies 
to initiate collection through offsetting of funds owed to the facilities. 
Finally, CMS did not transfer any of the 95 CMPs that became over 180 
days past due to the Department of the Treasury as required. However, 
we found that CMS sometimes took additional collection actions that 
are not required, such as sending past-due letters or making telephone 
calls to facility administrators. About half of the facilities contacted 
submitted payments to CMS within a month following such contact. 
Responsibilities for CMP collections are neither clearly defined nor 
commonly agreed upon. CMS central office staff view CMP 
collections as primarily a regional office responsibility. While some 
regional office staffs agree that their offices are primarily responsible 
for collecting CMPs, others expressed the belief that collection efforts 
are the responsibility of the central office. 
Databases used for tracking CMP collections contained inaccurate 
and incomplete information, causing collection errors and 
frustrating staff. In some cases, inaccurate information in CMS 
databases used for tracking CMP payments made them erroneously 
appear to be past due. CMS regional office staff reported that such data 
inaccuracies create a disincentive for them to attempt to collect past-
due CMPs because they do not want to request payment for a CMP that 
is not collectable or has been paid. In part, CMP data errors are 
attributable to CMSs using three different databases to process CMPs. 
These databases do not interface with each other and lack an effective 
means for staff to identify data errors. Lack of feedback to CMS about 
offsets by State Medicaid agencies also results in incomplete data. 
OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  ii  E X E C U T I V E   S U M M A R Y

RECOMMENDATIONS 
To ensure that all CMPs are fully collected as timely as possible, we 
recommend that CMS: 
Provide oversight to ensure that all required actions for collecting 
CMPs are taken. Specifically, CMS should ensure that collection staff 
provide facilities with complete notice when CMPs are due, assess 
interest on all past-due CMPs, routinely refer past-due CMPs to fiscal 
intermediaries and State Medicaid agencies to initiate collection 
through offsets from funds owed to the facilities, and routinely transfer 
CMPs over 180 days past due to the Department of the Treasury. 
Educate staff with written guidelines to clarify responsibilities for, 
and priority of, CMP collections.  CMS should issue a new set of 
guidelines with more clearly delineated responsibilities and increased 
emphasis on the importance of collections to provide staff with needed 
clarity about expectations for various actions. 
Ensure the accuracy of information contained in databases used for 
tracking CMP collections while making them easier to use. A review of 
CMP cases from CY 2002 revealed multiple instances of inaccurate data, 
which reportedly create a disincentive for staff to engage in required 
collection actions because they do not want to attempt to collect an incorrect 
amount or to collect CMPs that are not due or have already been paid. 
AGENCY COMMENTS 
CMS concurred with our recommendations.  The agency further commented 
that it has recently or will soon implement all of the OIG recommendations.   
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  iii    T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY ......................................... i 

INTRODUCTION ................................................ 1 

FINDINGS ....................................................... 5 

Past-due and uncollected CMPs ............................... 5 

CMS collection actions ....................................... 6 

Clarity of responsibilities ..................................... 8 

Databases used for tracking CMP collections ................... 9 

RECOMMENDATIONS ......................................... 12 

AGENCY COMMENTS ......................................... 15

ENDNOTES ..................................................... 16

APPENDIXES .................................................. 18 

A.  Detailed Methodology .................................... 18 

B. Agency Comments ....................................... 24 

ACKNOWLEDGMENTS ......................................... 27 

  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  iv    I N T R O D U C T I O N  

OBJECTIVE 
To determine the extent to which the Centers for Medicare & Medicaid 
Services (CMS) collected civil money penalties (CMPs) and took required 
collection actions for nursing home enforcement cases initiated in CY 2002. 
BACKGROUND 
The Social Security Act requires States to use a survey and certification 
process to verify that skilled nursing facilities and nursing facilities 
certified to participate in the Medicare and Medicaid programs maintain 
Federal standards regarding quality of care, safety, and patient rights.1 
Whenever State survey agencies determine that facilities are out of 
compliance with one or more of these standards, CMS may initiate 
enforcement remedies. The stated purpose of such enforcement remedies is 
to ensure prompt compliance with program requirements.2 
One enforcement remedy that CMS may use to address noncompliance 
found during nursing facility surveys is the CMP.  A CMP fine will vary, 
depending on the nature of the noncompliance, and may range from $50 to 
$10,000 per day until the facility is found to have returned to compliance or 
from $1,000 to $10,000 per instance of noncompliance. CMS has discretion 
to impose CMPs on facilities in a wide range of noncompliance situations.  
These include less serious situations, such as when surveyors find the 
potential for minimal harm to residents; instances when actual harm has 
occurred; and the most severe situations when noncompliance has already 
led, or could lead, to serious injury, harm, impairment or death to a 
resident.3 
In a recent study, the Office of Inspector General (OIG) found that, in  
CYs 2000 and 2001, CMS imposed CMPs in 51 percent of enforcement 
cases, with 85 percent of those cases involving citations for noncompliance 
at the level of actual harm or immediate jeopardy to residents health or 
safety.4  However, by December 2002, CMS had not fully collected from the 
facilities 14 percent of the CMPs that were considered collectable.5 
CMPs are the discretionary remedy CMS uses most frequently.6 Delays in 
collections, or lack of collections, could potentially undermine CMPs 
intended effect of ensuring that facilities promptly return to compliance. 
This inspection of the CMP collections process is part of OIGs ongoing 
evaluation of the quality of care provided to nursing facility residents, 
particularly as measured by survey deficiencies and by how States and 
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  1  I N T R O D U C T I O N  
CMS manage the enforcement process. This report builds on prior OIG 
work by thoroughly examining CMSs performance in and processes for 
collecting CMPs. 
CMP Due Date 
When CMS notifies a nursing facility that a CMP is being imposed, the 
nursing facility has 60 days to either file a request for an appeal or waive 
its right to an appeal.7, 8  The CMP becomes due 15 days after:  (1) the 60 
days has expired, (2) CMS receives an appeal waiver, (3) an appeal decision 
is made, or (4) the facility is terminated from the program and no appeal 
request is received.  The Social Security Act requires that CMS minimize 
the time between the identification of violations and final imposition of the 
remedies; thus, time between imposition and collection of the CMP should 
be as short as possible.9 
Required CMP Collection Actions 
CMS is required by Federal laws, regulation, and/or policy to take the 
following collection actions for CMPs:   
 	 Providing notificationRegulations require that CMS provide written 
notification to the facility that the CMP is due, including in that 
notification the amount of the CMP imposed, the amount due, the due 
date, the rate of interest to be charged on unpaid balances, and, for per-
day penalties, the days during which the CMP accrued.10 
 	 Assessing interestRegulations require that CMS assess interest on 
any unpaid balances beginning on the CMP due date and that CMS use 
a rate of interest that is determined by the Secretary of the Treasury.11 
 	 Initiating offsetsCMS policy requires that if a check is not received 
by the due date of the CMP, the [CMS regional office] initiates action to 
collect the CMP through offset of monies owed or owing to the nursing 
home.12  To initiate such an offset, CMS staff must instruct the 
appropriate fiscal intermediaries and State Medicaid agencies to deduct 
unpaid CMP balances from money owed to the facility.13 
 	 Transferring debtThe Debt Collection Improvement Act of 1996 
requires all debt owed to any Federal agency that is more than 180 days 
delinquent to be transferred to the Department of the Treasury for debt 
collection services.14 
In a 1999 program memorandum, CMS outlined its procedures for 
conducting the first three of these procedures.  Although this memorandum 
has an expiration date of May 1, 2000, CMS staff indicated that they still 
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  2  I N T R O D U C T I O N  
consider it in effect and that it contains the most current policies and 
procedures related to the collection of CMPs by CMS.  
OIG and GAO Reports Regarding CMP Collections 
The OIG report, Nursing Facility Enforcement:  The Use of Civil Money 
Penalties (2004), found that CMS had not fully collected 14 percent of the 
CMPs imposed in CYs 2000 and 2001.15  These unpaid CMPs involved 
nearly 550 cases and totaled $11.7 million for that 2-year period.  Further, 
the report revealed that CMS did not routinely refer past-due CMPs for 
offset by fiscal intermediaries and State Medicaid agencies. 
In its report, Civil Fines and Penalties Debt: Review of CMS Management 
and Collection Processes (2001), the Government Accountability Office 
(GAO) found that CMS did not transfer CMP debt to the Department of the 
Treasury for collection as required.16  In response to GAOs recommendation 
to implement procedures for meeting this requirement, CMS stated that it 
planned to begin referring all eligible debt, including CMPs, to the 
Department of the Treasury in fiscal year 2002.  
METHODOLOGY 
Scope 
This inspection focused on the 228 nursing facility enforcement cases in which  
(1) a CMP was imposed as a result of actions initiated during calendar year 
2002 and (2) the CMP was collectable and more than 30 days past due as of 
March 31, 2004. 
Methods 
The databases utilized in the course of this inspection included CMSs Long 
Term Care Enforcement Tracking System (LTC), Civil Money Penalty 
Tracking System (CMPTS), and Online Survey, Certification and Reporting 
System (OSCAR). We also obtained case documentation from CMS for all 228 
enforcement cases with past-due CMPs and interviewed staff at CMS central 
and regional offices about collection practices.  (See Appendix A for a detailed 
description of the inspection methodology.) 
To determine the extent to which CMS collected past-due CMPs, we 
examined data in CMPTS and reviewed case documentation obtained from 
CMS. Specifically, we determined whether each CMP had been collected in 
full, partially collected, or remained uncollected as of March 2004.  We also 
examined timeliness of collections. 
To determine the extent to which CMS took required collections actions, we 
examined case documentation of actions taken for the collection of each of 
the 228 past-due CMPs.  We also analyzed interview responses regarding 
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  3  I N T R O D U C T I O N  
CMS processes, procedures, and automated systems used to collect past-due 
CMPs. 
Quality Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  4    F I N D I N G S  
As of March 2004, CMS did not fully  Similar to OIG findings 
collect 4 percent of the CMPs imposed in  regarding CMPs imposed in 
2002 and collected another 8 percent well  2000 and 2001, we found that 12 
percent (228 out of 1,938) of 
after the due date 
collectable CMPs initiated in 
calendar year 2002 became past due by more than 30 days.  This 12 percent 
is composed of 4 percent of CMPs that were not fully collected by the end of 
our study period in March 2004, and 8 percent that were fully collected well 
past their due dates. 
CMS did not fully collect 79 past-due CMPs (4 percent of the total).   
By March 2004, over a year after the last of the 228 CMPs had been 
initiated, 79 (4 percent of the collectable CMPs) had not been fully collected.   
(See Table 1.)  Thirty-five of these CMPs had only part of their fines 
collected, and 44 CMPs had no money collected.  The total uncollected 
amount for these CMPs was $1.2 million. 
Table 1: CMPs More Than 30 Days Past Due 
Amount  Amount 
Collection Status  Past Due CMPs  Due**  Uncollected** 
(March 2004)  CMPs  Percent*  (millions)  (millions) 
Not Fully Collected  79  4%  $1.5  $1.2 
Partially Collected  35  2%  $0.7  $0.4 
  Nothing Collected  44  2%  $0.8  $0.8 
Fully Collected Very Late  149  8%  $1.6  $0.0 
Total Past Due  228  12%  $3.1  $1.2 
Source: OIG Analysis of 1,938 collectable CMP cases initiated in 2002 

*Percentage of the total 1,938 collectable CMPs. 

**The amounts due and uncollected do not include interest.

Among the 149 past-due CMPs that CMS eventually collected (8 percent of the 
total), the average collection time was 115 days. 
Once a due date for a CMP is initiated, facilities have 60 days in which they 
must accept the fine (waive their appeal rights), informally dispute the 
case, or file a formal appeal.  However, once these processes are completed 
or the 60 days have expired, a firm due date for the CMP is established.  
For the 149 CMPs CMS collected that were more than 30 days past due, the 
average collection time was 115 days.17  Seventeen percent of the 149 
collected CMPs were collected more than 6 months late, with the longest 
case taking 580 days to collect. 
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  5  FF II NN DD II NN GG SS  
Facilities were out of compliance on a subsequent inspection in 36 of the 44 
uncollected CMPs. 
CMPs are imposed primarily on nursing facilities cited for serious 
deficiencies and are part of an enforcement process designed to encourage 
prompt compliance with Federal standards. If collection is not timely, the 
intended effect of ensuring that facilities promptly return to and remain in 
compliance may be undermined. We found that as of March 2004, the 
facilities associated with 36 of the 44 uncollected CMPs were out of 
compliance during an inspection following the enforcement cycle when the 
unpaid CMP was imposed.18  Nineteen of the deficiencies were of a scope 
and severity level of G (actual harm that is not immediate jeopardy) or 
higher, and 18 of the subsequent cases were referred to CMS for further 
enforcement. For example, one facility was cited for noncompliance two 
more times in calendar years 2002 and 2003 and had two more CMPs 
imposed as a result, while the first CMP remained uncollected. One of the 
subsequent CMPs resulted from an incident in which a resident had to be 
hospitalized for pressure ulcers (bed sores) so severe that surgery was 
required. At the time of our data collection, only partial collection had 
occurred on the second CMP, while the first and third remained entirely 
uncollected. 
Federal requirements specify 
CMS did not take all required actions to 
certain actions that CMS is 
collect 94 percent of past-due CMPs, but did 
required to take to ensure that 
take some actions beyond those required 
CMPs are collected from 
that improved collection results 
noncompliant facilities: providing 
facilities with complete notification that the CMP is due, assessing interest 
on unpaid balances, offsetting CMPs from funds owed to facilities, and 
transferring delinquent debt to the Department of the Treasury. We found 
that CMS took all actions that were required for only 6 percent of past due 
CMPs, with the remaining 94 percent missing at least one required action. 
(See Table 2.) 
The first of these actions, complete notification that the CMP is due, is 
required for all CMPs unless there is a settlement agreement containing 
the necessary information. CMS need take the remaining actions only if 
facilities do not pay by the due date. The second action, assessment of 
interest, serves as an incentive for facilities to promptly remit payment. 
The last two actions, offsets and referrals to the Department of the 
Treasury, recognize that some facilities may not promptly pay their fines 
and that the Government must collect payment through other means. 
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Table 2: CMS Did Not Take All Required Actions 
Past-Due CMPs With 
Required Action Not Taken
Applicable 

Required Action 
 CMPs*  CMPs  Percent 
Complete Notice  221  88  40% 
Interest Assessment  228  164  72% 
Referral for Offset  228  162  71% 
Transfer to Treasury*  95  95  100% 
Total (All Applicable Actions)  228  215**  94% 
Source: OIG analysis of 228 CMPs initiated in 2002 and past due by more than 30 days

*Not required for cases with settlement agreements; transfer to Treasury only required for cases 

that were unpaid after 180 days.

**This figure is not intended to represent the sum of the individual actions listed above. 

CMS did not send complete notification of their fines to 40 percent of facilities 
with past-due CMPs. 
Case documentation showed that CMS did not provide any written notice to 
4 percent (10 out of the 228 past-due CMPs) of the facilities with CMPs that 
became past due by more than 30 days. In the remaining cases, we 
examined the notices to determine whether they contained required 
information, including the amount of the CMP; the amount due; the due 
date; the rate of interest to be charged on unpaid balances; and, for per-day 
penalties, the dates the CMP accrued. Thirteen percent of notices did not 
include a due date for the CMP and one notice omitted the amount that was 
due, both of which are critical pieces of information facilities need to remit 
payment on time. The most commonly omitted information, the interest 
rate to be charged on any unpaid balances, was missing from 23 percent of 
notices. 
CMS did not assess interest in 72 percent of past-due CMPs as required. 
Regulations require the assessment of interest on unpaid balances after the 
due date.19 CMS assessed interest on only 28 percent of past-due CMPs and 
actually collected it for only 21 percent. 
CMS did not refer 71 percent of past-due CMPs to fiscal intermediaries and State 
Medicaid agencies to initiate offsets. 
Regulations permit CMS to collect CMPs via a deduction from monies owed 
to the facilities, called offsets, and CMS has instructed the regional offices 
to do so if a check is not received by the due date.20,21 We found that CMS 
only initiated offsets for 29 percent of past-due CMPs. Further, many of 
these referrals occurred well after the CMPs were duean average of 83 
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days after the due date for referrals to fiscal intermediaries and 88 days 
after the due date for referrals to State Medicaid agencies. 
CMS did not transfer any CMPs that were over 180 days past due to the 
Department of the Treasury, as required. 
CMS documented that, following issuance of GAOs report in 2001, it 
transferred 10 CMPs imposed between 1996 and 1998 to the Department of 
the Treasury. We found no evidence that any further CMP debt has been 
transferred, including the 95 eligible CMPs that were initiated in 2002. 
CMS sometimes uses past-due letters or telephone calls to improve collection 
results. 
CMS mailed past-due letters to 27 percent of facilities with CMPs that were 
not paid more than 30 days after their due dates and received payment 
from 48 percent (30 out of 62) of these facilities within a month of the letter, 
avoiding the need for further collection efforts. Similarly, CMS staff 
reported making direct telephone calls to facility administrators in 18 
percent of past-due cases and received payment within a month from 50 
percent (21 out of 42) of these facilities. 
Interviews with CMS staff in 
Responsibilities for CMP collections are 
central and regional offices 
neither clearly defined nor commonly 
suggest that there is 
agreed upon 
uncertainty about 
responsibilities for collection of 
CMPs. CMS central office staff viewed CMP collections as primarily a 
regional office responsibility, citing written guidance in a 1999 Program 
Memorandum (since expired) describing which CMS staffs were responsible 
for various aspects of CMP collections. Regional office staff perceptions 
varied. Staff in one regional office expressed the view that all collection 
efforts, from receiving payments to following up on late cases, are the 
responsibility of the central office. Other regional staff felt they were 
primarily responsible for collecting CMPs, but argued that regional offices 
should not act as collection agencies and suggested that collection efforts 
should be either fully centralized or should become a contracted function. 
The failure to complete required collection activities described earlier is 
partially attributable to the lack of clarity of responsibilities and 
procedures. For example, interviews with CMS staff suggested that there 
are problems that may contribute to interest not being assessed as it 
should. Some regional office staff reported that the rules for calculating 
and applying interest are not well defined, and others expressed confusion 
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about who within CMS is responsible for assessing interest.  Even when a 
rate is known, staff indicated that calculating the interest can be difficult. 
Another example of lack of clarity involves transferring cases to the 
Department of the Treasury for collections.  Regional offices were unaware 
that it is required and some did not even know that this is an option. 
Databases used for tracking CMP  Based on a comparison of 
collections contained inaccurate and  data contained in CMSs 
CMPTS to documents 
incomplete information, causing collection 
obtained from CMSs 
errors and frustrating staff 
regional offices, we 
determined that 32 percent (109 out of 337) of CMPs that appeared to be 
past due by more than 30 days were identified incorrectly as the result of 
inaccurate data.  Adjustments resulting from these errors produced the 228 
past-due CMPs we focused on in our inspection. (See Table A2 in Appendix 
A.) Specifically, 65 of the 109 incorrectly identified CMPs showed past-due 
balances that had already been paid in full or were not due for other 
reasons. Another 41 of the 109 CMPs were missing information to indicate 
that the case was on hold for an appeal, bankruptcy, or criminal 
investigation by the Department of Justice.  Finally, three CMPs had been 
rescinded, yet the database still listed the CMPs as owed and delinquent.  
In addition to inaccuracies that made CMPs erroneously appear past due, 
we found other data errors such as incorrect CMP due dates and amounts.22 
CMS regional office staff reported that data inaccuracies create a 
disincentive for them to pursue collection of past-due CMPs.  Staff reported 
that inaccurate data make it difficult to determine which CMPs need 
collection efforts and that they do not want to request payment for a CMP 
that is not due.  One region reported having sent letters to facilities 
requesting payment for past-due CMPs only to find that some payments 
had been remitted on time but not recorded in CMPTS.  Regional staff also 
reported that, rather than being able to examine multiple past-due cases at 
once, they must review CMP cases individually in the CMPTS, making 
collection activities time consuming. If errors lead to facilities making 
payments for the wrong amount, staff reported that extra steps must then 
be taken to refund any overpayment or to collect the remainder of the CMP. 
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Shortcomings in the database systems increase the potential for data errors and 
missing information. 
In part, CMP data errors and staff frustration are attributable to how the 
information is accumulated and entered into the three distinct databases 
that CMS uses for processing CMPs. (See Figure 1.) Because these three 
systems do not interface, information for the same CMP must be entered 
into them separately. Entering data multiple times increases the 
opportunities for data-entry errors, missing data, and inconsistent updates 
across systems. 
Figure 1:  CMS Database Information Entry Process 
CMP Transmittal Form 
CMS Regional Office Staff Enter  CMS Office of Financial Management 
Amount and Date Due Information  Staff Enter Payment Information 
LTC  CMPTS  Financial Accounting and 
Control System 
Source: OIG analysis of databases and interviews with CMS staff, 2004 
To help identify and correct inaccurate information, CMSs Office of 
Financial Management generates and distributes a monthly report of all 
CMPs listed in CMPTS as uncollected. In theory, regional staff could use 
this report to validate information in paper files and the LTC database. 
While some regional staff reported that they use the report each month, 
others reported they were unaware of its existence and still others indicated 
that it is not useful, difficult to read, and often not current. 
State Medicaid agencies do not always notify CMS of collections through 
offsets, resulting in incomplete collections data. 
Another source of data inaccuracies involves offsets. CMS referred 66 
CMPs to State Medicaid agencies for offset. For 29 of those, State Medicaid 
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agencies either failed to collect the Medicaid portions or failed to notify 
CMS that they had collected them. 
CMS staff report that they do not always know when State Medicaid 
agencies actually offset the funds; therefore, this information is sometimes 
not entered into CMPTS.  Collections made by the State Medicaid agency 
are retained by the State.  If State Medicaid agencies do not send CMS a 
notice of the collection, the Medicaid portion of the CMP appears to be 
uncollected in the CMPTS.  CMS staffs report that States are inconsistent 
in sending such notices. 
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 R E C O M M E N D A T I O N S
Based on prior and current OIG studies, it is clear that nursing facilities 
pay the majority of CMPs when they are due, meaning that CMS does not 
need to take additional steps to collect most fines.  However, our analysis 
demonstrates that when extra collection efforts are called for, CMS is not 
fully successful and often does not take required actions.  Of the 228 CMPs 
initiated in 2002 that became more than 30 days past due, 79 were not fully 
collected by March 2004, the end of our study period. Further, when 
collection occurred in cases that became more than 30 days past due, it was 
often very late, with an average collection time of 115 days past the due 
date.  
Several factors within CMSs control affect timeliness of CMP collections. 
For example, CMS did not take all required collection actions for 94 percent 
of the past-due CMPs.  Further, lack of clear roles and responsibilities and 
problems with automated systems create disincentives for CMS staff to 
follow up on past-due cases.  
Timely collection of all CMPs is important for ensuring that nursing 
facilities return to and remain in compliance with Federal standards of 
patient care. To ensure that all CMPs are fully collected as timely as 
possible, we recommend the following to CMS: 
Provide Oversight to Ensure That All Required Actions for Collecting CMPs Are 
Taken. 
Specifically, CMS should ensure that staff: 
Provide a complete notice to all facilities upon which CMPs are imposed Not 
sending notification, or not including information such as the due date or 
the amount due, can make it difficult for facilities to make payments 
accurately and timely. Development of a standardized notice for use by 
CMS staff could help eliminate some errors. 
Assess interest on all past-due CMPs Clarifying the circumstances under 
which headquarters or regional office staffs are responsible for assessing 
interest would be helpful, as would having the appropriate interest rates 
easily accessible by regional office staff.  An electronic tool that calculates 
payments and interest on installment plans may be useful.  
Routinely refer past-due CMPs to fiscal intermediaries and State Medicaid 
agencies for collection using offsets from funds owed to the facilities Setting a 
specific point in time after the due date for initiation of offsets could assist 
in making collection of past-due CMPs by offset more routine. 
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Transfer CMPs over 180 days past due to the Department of the Treasury as 
required 
Provide Staff With Written Guidelines to Clarify Responsibilities For and Priority 
of CMP Collections. 
Although CMS outlined CMP collections procedures in 1999, they have 
expired. A new communication, with more clearly delineated 
responsibilities and increased emphasis on the importance of collections, 
would provide staff with needed clarity about expectations for various 
actions.  Guidelines could be most useful if they included timelines for 
actions such as assessing and collecting interest, referring cases for offset, 
and transferring debt to the Department of the Treasury.  New guidelines 
should also articulate the importance of CMP collections for ensuring that 
nursing facilities meet standards of care for Medicare and Medicaid 
beneficiaries. 
Ensure the Accuracy of Information Contained in Databases Used for Tracking 
CMP Collections and Make Them Easier to Use. 
A review of CMP cases from 2002 revealed multiple instances in which 
inaccurate data made CMPs appear to be past dueand thus in need of 
collection actionswhen in fact no collection was needed.  These inaccuracies 
included incomplete data, unrecorded payments, inconsistent information 
between databases, and incorrect due dates and dollar amounts.  Some likely 
causes of these data errors are multiple data entry points and separate 
databases that are unable to communicate or update information.  Reports 
that could be used to detect errors are often not used by CMS staff.   
Data inaccuracies reportedly create a disincentive for staff to engage in 
necessary and required collection actions because they do not want to attempt 
collection of incorrect amounts or CMPs that are not due or have already been 
paid.  Several options for improvements include: 
Reducing, where possible, the number of multiple data entry points for the same 
information and increasing the interfaces between databases  Dual data entry at 
both the regional offices and central office increases the effort expended and 
creates more opportunity for errors. 
Reducing data entry errors  Data entry errors could also be reduced by 
building logic safeguards into various fields in the database.  For example, 
date fields could be programmed to reject an impossible date. 
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Routine reconciliation between CMP collection data sources Routine use of 
monthly reports regarding uncollected CMPs could help identify data 
inaccuracies and place increased emphasis on collections. 
Providing regional office staffs with an easier method for tracking payments 
Providing regional offices with the ability to print reports directly from 
CMPTS, rather than requiring them to look up each CMP individually, 
could make it easier for staff to take required collection actions and 
eliminate a source of frustration. 
Developing reliable and consistent feedback methods with State Medicaid agencies 
to better track offsets 
OIG separately furnished CMS with information regarding the CMPs 
reviewed so that CMS may take appropriate collection actions in these 
cases. 
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CMS concurred with our recommendations.  The agency further commented 
that it has recently or will soon implement all of the OIG recommendations 
and had initiated an internal quality improvement project in March 2004.  
The full text of CMSs comments is presented in Appendix B. 
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1	 Sections 1819(f)(1) and 1919(f)(1) of the Social Security Act, 42 U.S.C.  
 1395i-3(f)(1), 1396r(f)(1). 
2	 42 C.F.R.  488.402(a) (2003). 
3	  42 C.F.R.  488.301 (2003). 
4	 Department of Health & Human Services, Office of Inspector General, 
Draft Report, Nursing Facility Enforcement:  The Use of Civil Money 
Penalties, OEI-06-02-00720, March 2004. 
5	 CMPs are not collectable when an appeal hearing is pending, a 
bankruptcy settlement is in process, the Department of Justice has 
requested that collection is held while a criminal investigation is being 
conducted, or the due date has been extended by an agreement with 
CMS (e.g., the facility is paying in installments). 
6	 Department of Health and Human Services, Office of Inspector General, 
Draft Report, Nursing Facility Enforcement:  The Use of Civil Money 
Penalties, OEI-06-02-00720, March 2004. 
7	 42 C.F.R.  498.40(a)(2) (2003). 
8	 42 C.F.R.  488.436(a) (2003). 
9	 Section 1819(h)(2)(B) of the Social Security Act. 
10	 42 C.F.R.  488.440(d) (2003). 
11	 42 C.F.R.  488.442(d) (2003). 
12	 CMS Program Memorandum Regional Offices Standards and 
Certification, Transmittal No. 99-1, April 1999.    
13	 42 C.F.R.  488.442(c) (2003). 
14	 Debt Collection Improvement Act of 1996, Pub. L. No. 104-134, 110 Stat. 
1321 (1996). 
  OEI-06-03-00420  NURSING HOME ENFORCEMENT:  COLLECTION OF CIVIL MONEY PENALTIES  16  15 Department of Health and Human Services, Office of Inspector General, 
Draft Report, Nursing Facility Enforcement:  The Use of Civil Money 
Penalties, OEI-06-02-00720, March 2004. 
16  U.S. Government Accountability Office, Civil Fines and Penalties Debt:  
Review of CMS Management and Collection Processes,  GAO-02-116, 
Appendix II, page 3(2), December 2001. 
17	 The median time past due was 73 days.  
18	 These facilities were out of compliance with deficiencies of a scope and 
severity of D (potential for more than minimal harm) or higher. 
19	 42 C.F.R.  488.442(d) (2003). 
20	 42 C.F.R.  488.442(c) (2003). 
21	 CMS Program Memorandum Regional Offices Standards and 
Certification, Transmittal No. 99-1, April 1999. 
22	 Data errors found were corrected prior to data analysis and do not affect 
any of the above findings. 
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DETAILED METHODOLOGY 
Data Sources 
Documentary Evidence  
We requested case information and supporting documentation from the 
CMS regional offices for each of the cases we initially identified as more 
than 30 days past due. Information requested included whether 
additional payments had been made, whether CMS staff had taken the 
required actions, whether additional actions beyond those required had 
been taken, and difficulties experienced in trying to collect the CMP.  We 
requested all collection information from the time the CMP became due 
through March 2004 (the end of our documentation data collection 
period).  We also requested supporting documentation, including copies of 
all letters to facilities notifying them that the CMP was due.  We received 
responses for 100 percent of the requested cases.  Finally, we used a 
worksheet to capture data extracted from the regional office responses as 
supporting documentation. 
Interviews 
We conducted interviews with staff in CMS central and regional offices in 
September 2003.  Interviews with staff at CMS regional offices provided 
information about the procedures used in each region and any difficulties 
encountered when collecting CMPs.  CMS central office staff in the Office 
of Financial Management participated in interviews designed to capture 
the role of CMSs central office in the collection of CMPs and difficulties 
with tracking CMP payments. OFM staff also demonstrated the 
procedures for processing CMP payments, including use of the 
management information systems. 
Databases 
The CMS databases used for this study were LTC, CMPTS, and OSCAR. 
LTC  The LTC database is a compilation of each CMS regions nursing 
facility enforcement case files.  Caseworkers update this information as 
enforcement actions occur.   The database contains information about 
remedy imposition, including CMPs, as well as the dates of the surveys 
conducted during the enforcement cycle. 
CMPTS  The CMPTS is the centralized CMS database used for tracking 
the collection and allocation of CMP payments.  There are two parts to 
this database:  payments due and payments received.  CMS regional office 
staff enter information into the CMP payments due part; CMS central 
office staff enters information about payments collected.  This database 
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was the source of information about the CMP amount due, the due date, 
the amount paid, and the date of payment. 
OSCAR We used CMSs nationwide database of nursing facility 
surveys, OSCAR, to explore the performance of the facilities with 
unpaid past-due CMPs.  OSCAR maintains information on the four 
most recent standard surveys of certified nursing facilities nationwide, 
as well as complaint-generated surveys. 
Initial Case Identification 
Identification of Enforcement Cases With CMPs Imposed  Using LTC, we 
identified 4,173 enforcement cases initiated in CY 2002.  From that group, 
we identified 2,149 cases in which CMPs were imposed. These CMPs 
resulted from both standard and complaint surveys.  We used the year 
2002 because it was the most recent year in which we could expect the 
majority of CMPs to have become due. CMP due dates are often delayed 
by appeals. (See Table A1.) 
Table A1: Initial CMP Collections Cases Selected 
Use of CMPs 
CMS Enforcement Cases  4,173 cases 
CMPs Imposed  2,149 cases 
Collectability of CMPs 
Uncollectable  167 CMPs 
Collectable  1,982 CMPs 
Payment Status for Collectable CMPs 
Paid in Full on Time  928 CMPs 
Paid 1 to 30 Days Late  717 CMPs 
CMPs More Than 30 Days Late  337 CMPs 
Source: OIG analysis of 4,173 nursing facility enforcement cases initiated in 2002 
We matched the imposed CMPs we found in LTC to CMPs listed in 
CMPTS.1  We used the due date from CMPTS to identify CMPs that 
became past due, and the amounts due and paid to determine whether the 
CMPs had been paid, partially paid, or remained unpaid. 
1 Some cleaning of the LTC and CMPTS data was necessary.  We were able to match all 2,149 
CMPs between the CMPTS and LTC databases using the CMP collection number (present 
in both databases).   In LTC, cases in which a CMP was rescinded by an Informal Dispute 
Resolution or regional office decision were recoded, missing CMP collection numbers were 
added to match those in the CMPTS, and amounts and dates entered in error were 
corrected using data obtained from alternative sources.  In CMPTS, cases in which the CMP 
had been rescinded were eliminated, duplicate files were deleted, and amounts due and paid 
and missing or incorrect dates were reconciled with LTC. 
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Identification of Collectable CMPs  We used information from LTC to 
determine whether the CMPs imposed were collectable.  One hundred 
sixty-seven CMPs were uncollectable because they were on hold while the 
facility appealed the CMP (115), the facility was undergoing bankruptcy 
proceedings (19), the CMP was being paid in installments and the final 
installment was not yet due (30), or the CMP had not yet reached the due 
date (3). This process yielded 1,982 collectable CMPs. 
Determining Timeliness of Payment  The LTC and CMPTS data showed that 
53 percent (1,054) of the 1,982 collectable CMPs imposed in 2002 and due 
as of February 1, 2004, were paid at least 1 day late, partially paid, or not 
paid at all.2  The 2004 OIG study found that, on average, CMPs were paid 
32 days after the due date.3  Thus, for this inspection, we chose to more 
thoroughly examine all 337 CMPs that were more than 30 days past due 
to capture the more extreme cases that were overdue by more days than 
average. 
Data Collection 
Using a structured data collection instrument, we sent data requests to 
the corresponding regional offices for each of the 337 CMPs identified as 
past due by more than 30 days.  Each request included information on the 
CMP, such as the facility identifiers, the CMP collection number, the 
survey completion date, the CMP due date, the amount due, and any 
amounts paid.  We asked whether any additional payments were made on 
the CMP. We also asked regional office staff to place a check next to each 
of the actions taken for each CMP case and to describe any additional 
actions that we had not listed.  The actions listed were sending a letter of 
notification that the CMP was due, assessing interest, referring the case 
for offset by the fiscal intermediary and/or State Medicaid agency, 
transferring the case to the Department of the Treasury, sending 
additional letters or e-mails to the provider, making telephone calls to the 
provider, and other actions.  We also asked staff to describe any 
difficulties their offices experienced in trying to collect the CMP and 
requested that they attach supporting documentation for each action 
taken.  We received information for 100 percent of the CMP case requests. 
2 Before we requested data from the regional offices, we captured all CMPs past due as of 
February 1, 2004, because that was the date the data were downloaded and sent to us from 
CMS. We were later able to document payments through March 2004 from data received 
from regional offices. 
3 Department of Health and Human Services, Office of Inspector General, Draft Report, 
Nursing Facility Enforcement:  The Use of Civil Money Penalties, OEI-06-02-00720. 
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We also requested information and documentation from the CMS Office of 
Financial Management regarding all nursing facility CMPs transferred to 
the Department of the Treasury.4 
Data Analysis 
We performed data processing and analyses using SAS, Microsoft Access, 
and Microsoft Excel. 
Qualitative Data  We transcribed notes from all responses to CMS regional 
office and central office interviews. Analysts then reviewed the material 
from all of the interviews to identify similarities and differences among 
the responses of different offices and to gauge the impact of the 
information on CMP collections.  In conjunction with the quantitative case 
data, this qualitative analysis of staff interviews is used throughout the 
report to further explain our findings. 
Documentary Evidence  We entered qualitative and quantitative 
information from the documents received from the regional offices into an 
Access database. We used information that was provided by regional 
office staff about CMP payments or dates to update information.  We also 
added data extracted from the documentation about the presence and 
completeness of letters notifying the facility that the CMP was due, 
interest assessed, offsets, other collection efforts, and reported difficulties 
encountered by CMS staff.   
Obtaining the Final Cases  Analysis of data from the documentary evidence 
indicated that 109 of the 337 CMPs were inappropriately coded as past 
due because of data errors or incomplete information.  Three CMPs had 
been rescinded, reducing the number of CMPs imposed from 2,149 to 
2,146. Forty-one CMPs were on hold for appeals, bankruptcies, 
installments, or criminal investigation by the Department of Justice, 
increasing the number of uncollectable CMPs from 167 to 208.  Sixty-five 
CMPs were misidentified as past due because of inaccurate information in 
the database, increasing the number paid in full on time from 928 to 993.  
Table A2 presents the final, corrected numbers of CMPs imposed and their 
collection status. 
4 Our interviews with CMS regional and central office staff indicated that, to date, any 
transfer of cases to the Department of the Treasury was done by the CMS Office of 
Financial Management. 
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Table A2:  Final CMP Collections Cases 
Use of CMPs 
CMS Enforcement Cases  4,173 cases 
CMPs Imposed  2,146 cases 
Collectability of CMPs 
Uncollectable  208 CMPs 
Collectable  1,938 CMPs 
Payment Status for Collectable CMPs 
Paid in Full on Time  928 CMPs 
Paid 1 to 30 Days Late  717 CMPs 
CMPs More Than 30 Days Late  228 CMPs 
Source: OIG analysis of 4,173 nursing facility enforcement cases initiated in 2002 
Eventual Collection of CMPs  We used information in CMPTS, 
supplemented by updated information from the documentary evidence, to 
determine the proportion of the 228 past-due CMPs that were fully, 
partially, or not at all collected by March 31, 2004, the end of our study 
period.  The due date was subtracted from the collection date to determine 
the number of days past due.  February 1, 2004 (the date the data were 
extracted), was used as the default collection date for cases that were not 
yet collected so we could compute the number of days they were past due 
as of the time of this study.  Descriptive statistics were used to find the 
minimum and maximum days late per group, average days late, 
percentage over 180 days past due, and the numbers with outstanding 
balances for over 1 year. 
Facility Performance for Uncollected CMPs  Provider numbers were used to 
match the LTC files for the uncollected CMPs with OSCAR data to 
explore past and subsequent performance of the facilities.  Each facilitys 
performance on standard and complaint surveys was reviewed and 
summarized.  Information in the Notes field in LTC was used to provide 
additional details of visit findings. 
Actions Taken by CMS   Data extracted from the documentary evidence 
provided by CMS regional offices, data in CMPTS, and data from the 
Office of Financial Management were used to determine actions taken. 
The past-due letters received from the regional offices were each reviewed 
to describe completeness of their content.  We did not receive letters for 29 
CMPs: 7 CMPs did not require letters to be sent (i.e., settlement 
agreements); the regional office reported that a letter was sent but failed 
to attach it for 12 CMPs; and no letters were sent at all for 10 CMPs.  
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Interest assessment and payment information was obtained from CMPTS.  
Information regarding referrals for offsets and additional actions was 
obtained from the documentary evidence provided by the regional offices. 
The CMS Office of Financial Management provided information on CMPs 
transferred to the Department of the Treasury for collection. 
Contributors to Noncollection   Qualitative interview data were used to 
explore database shortcomings, clarity of roles and responsibilities, and 
staff incentive to follow up on past-due cases. Whenever possible, the 
qualitative data findings were supplemented by quantitative data from 
the databases and coded regional office documentation. 
Data Limitations 
Despite extensive data cleaning efforts, it is possible that identification of 
some past-due CMPs may have been impeded by dates entered 
erroneously in the CMPTS data that were not discovered during data 
cleaning. 
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Agency Comments to Draft Report 
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 A P P E N D I X ~ B  

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This report was prepared under the direction of Judith V. Tyler, Regional 
Inspector General for Evaluation and Inspections in the Dallas Regional 
Office, and Kevin Golladay, Assistant Regional Inspector General.  Other 
principal Office of Evaluation and Inspections staff who contributed 
include: 
Amy Ashcraft, Team Leader 
Susan M. Wolfe, Ph.D., Project Leader 
A. Blaine Collins, Program Analyst 
Ruth Ann Dorrill, Program Analyst 
Clark Thomas, Ph.D., Program Analyst 
Sandy Khoury, Program Specialist 
Technical Assistance 
Barbara Tedesco, Mathematical Statistician 
Field Assistance 
The following individuals assisted with regional office interviews: 
Tara Bernabe, Program Analyst 
Sylvia Chin, Program Analyst 
Tricia Fields, Program Analyst 
Graham Rawsthorn, Assistant Regional Inspector General, Atlanta 
David Rudich, Program Analyst 
Marco Villagrana, Program Analyst 
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