HHS OIG Releases 2014 Work Plan

Every year the U.S. Department of Health and Human Services Office of the Inspector General (OIG) publishes a work plan that provides industry stakeholders with insight as to the OIG’s new and ongoing auditing and investigative activities in the upcoming year.`

Last year’s data reveals an intense governmental focus on combating fraud, waste and abuse in the federally funded healthcare programs. For example, in FY 2013 the OIG reported exclusions of 3,214 individuals and entities from participation in Federal health care programs; 960 criminal actions against individuals or entities that engaged in crimes against HHS programs; and 472 civil actions. The latter includes false claims and unjust-enrichment lawsuits filed in Federal district court, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters.

Here’s a snapshot of the OIG’s activities in the upcoming year.

Hospitals & Home Health Agencies

Where hospitals are concerned, the government will focus on hospital related policies and procedures, billing and payments, and patient quality and safety. In the category of home health services, among other things, the OIG will continue its focus on the extent to which home health agencies (HHAs) are complying with State requirements for conducting criminal background checks on HHA applicants and employees. Federal law requires that HHAs comply with all applicable State and local laws and regulations and nearly all States have laws prohibiting certain health-care-related entities from employing individuals with prohibited criminal convictions.

Physicians & Chiropractors

Physician noncompliance with assignment rules and improper billing of Medicare beneficiaries also continues to be the focus of the OIG.

More attention is being paid to chiropractors in the 2014 Work Plan. One of OIG’s new projects focuses on chiropractors billing and payment practices. Specifically, the OIG plans to compile the results of prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities. Prior OIG work identified inappropriate payments for chiropractic services that the government determined were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent.


DME suppliers continue to be heavily scrutinized by the OIG. The agency, for example, will once again evaluate the reasonableness of the Medicare fees for various medical equipment items, including commode chairs, folding walkers, and transcutaneous electrical nerve stimulators, by comparing Medicare payments for such products with non-Medicare payers. Medicare reimbursement rates for parenteral nutrition will also be examined by comparison with non-Medicare payers. Previous OIG work found that Medicare allowances for parenteral nutrition averaged 45 percent higher than Medicaid prices, 78 percent higher than prices available to Medicare risk-contract health maintenance organizations (HMO), and 11 times higher than some manufacturers contract prices. Additionally, the OIG will focus on the competitive bidding process and pricing determinations.

It should come of no surprise to anyone following the allegation of wide-scale fraud at the Scooter Store’s over the past several years that the OIG will be focusing on compliance with Medicare standards in billing and payments for power mobility devices, including the new face-to-face evaluation requirement.

Medical necessity and compliance with Medicare requirements for the two most commonly prescribed DME supplies — nebulizers and home blood glucose supplies — will also be analyzed by the OIG. According to the government, prior reviews determined that suppliers of diabetic related supplies did not always comply with Federal requirements.

Other Providers and Suppliers

The OIG likewise will focus on the following providers and suppliers and their activities: a) questionable billing practices by laboratories; b) inappropriate payments for evaluation and management services; c) high utilization of sleep testing procedures; d) portable x-ray supplier compliance with transportation and set-up fee requirements; and e) enrollment and credentialing of mental health care providers, among others.

If you have questions about the OIG, the Work Plan, compliance planning, Medicare participation, enrollment or revalidation, or need other legal assistance, please contact our office.