Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

NURSING HOME ENFORCEMENT:


COLLECTION OF CIVIL MONEY 


PENALTIES


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. 

` 
Δ EXECUTIVE SUMMAR 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. 

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EXE CUTIVE S U MMAR Y

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 pastdue 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 pastdue 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 CMS’s 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. 

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EXE CUTIVE S U MMAR 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. 

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Δ T ABLE OF CONTENTS 

EXECUTI VE SUMMARY ......................................... i 

INTRODUCTI ON ................................................ 1 

FINDI NGS ....................................................... 5 

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

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

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

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

RECOM M E NDATI O NS ......................................... 12 

AGENCY COMME NTS ......................................... 15

ENDNOTE S ..................................................... 16

APPENDI XES .................................................. 18 

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

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

ACKN O W LEDGMENTS ......................................... 27 

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Δ INTRODU C TION 

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 OIG’s ongoing 

evaluation of the quality of care provided to nursing facility residents, 

particularly as measured by survey deficiencies and by how States and 

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INTROD UCT ION 

CMS manage the enforcement process. This report builds on prior OIG 

work by thoroughly examining CMS’s 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 notification—Regulations 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 perday penalties, the days during which the CMP accrued.10 

• Assessing interest—Regulations 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 offsets—CMS 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 debt—The 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 

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INTROD UCT ION 

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 GAO’s 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 CMS’s 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 

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INTROD UCT ION 

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 President’s Council on Integrity and Efficiency. 

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Δ FINDINGS 

As of March 2004, CMS did not fully 

collect 4 percent of the CMPs imposed in 

2002 and collected another 8 percent well 

after the due date 

Similar to OIG findings 

regarding CMPs imposed in 

2000 and 2001, we found that 12 

percent (228 out of 1,938) of 

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 

Collection Status 

(March 2004) 

Past Due CMPs 

CMPs Percent* 

Amount 

Due** 

(millions) 

Amount 

Uncollected** 

(millions) 

Not Fully Collected 

Partially Collected 

 Nothing Collected 

Fully Collected Very Late 

79 

35 

44 

149 

4% 

2% 

2% 

8% 

$1.5 

$0.7 

$0.8 

$1.6 

$1.2 

$0.4 

$0.8 

$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. 

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F I NDING S 

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. 

CMS did not take all required actions to 

collect 94 percent of past-due CMPs, but did 

take some actions beyond those required 

that improved collection results 

Federal requirements specify 

certain actions that CMS is 

required to take to ensure that 

CMPs are collected from 

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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F I NDING S 

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 due—an average of 83 

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F I NDING S 

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 GAO’s 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. 

Responsibilities for CMP collections are 

neither clearly defined nor commonly 

agreed upon 

Interviews with CMS staff in 

central and regional offices 

suggest that there is 

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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F I NDING S 

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 

collections contained inaccurate and 

incomplete information, causing collection 

errors and frustrating staff 

Based on a comparison of 

data contained in CMS’s 

CMPTS to documents 

obtained from CMS’s 

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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F I NDING S 

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: CM S Database Inform ation Entry Process 

CM P Transm ittal Form 

CM S Regional Office Staff Enter CM S Office of Financial M anagem ent 

Am ount and Date Due Inform ation Staff Enter Paym ent Inform ation 

LTC CM PTS Financial Accounting and 

Control System 

Source: OIG analysis of databases and interviews with CM S staff, 2004 

To help identify and correct inaccurate information, CMS’s 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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F I NDING S 

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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ΔΔ RECO MME N D A T I O N S RECOMME NDA TIONS 

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 CMS’s 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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R E C O MMENDA T I O N S 

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 due—and thus in need of 

collection actions—when 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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R E C O MMENDA T I O N S 

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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Δ AGENCY COMMENTS 

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 CMS’s comments is presented in Appendix B. 

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Δ ENDNOTE S 

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). 

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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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Δ APPENDIX A 

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 CMS’s 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 region’s 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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APP E N D I X A 

was the source of information about the CMP amount due, the due date, 

the amount paid, and the date of payment. 

OSCAR We used CMS’s 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 

CMPs Imposed 

4,173 cases 

2,149 cases 

Collectability of CMPs 

Uncollectable 

Collectable 

167 CMPs 

1,982 CMPs 

Payment Status for Collectable CMPs 

Paid in Full on Time 

Paid 1 to 30 Days Late 

CMPs More Than 30 Days Late 

928 CMPs 

717 CMPs 

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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APP E N D I X A 

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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APP E N D I X A 

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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APP E N D I X A 

Table A2: Final CMP Collections Cases 

Use of CMPs 

CMS Enforcement Cases 

CMPs Imposed 

4,173 cases 

2,146 cases 

Collectability of CMPs 

Uncollectable 

Collectable 

208 CMPs 

1,938 CMPs 

Payment Status for Collectable CMPs 

Paid in Full on Time 

Paid 1 to 30 Days Late 

CMPs More Than 30 Days Late 

928 CMPs 

717 CMPs 

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 facility’s 

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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APP E N D I X A 

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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Δ APPENDIX B 

Agency Comments to Draft Report 

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APP E N D I X ~B 

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APP E N D I X ~B 

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Δ ACKNOWLEDGMENTS 

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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