The OIG Work Plan 2016 – An Introduction

The OIG Work Plan 2016 was released by the Office of Inspector General (OIG) on November 2, 2015.  The OIG Work Plan 2016 is an evolving document which outlines the OIG‘s oversight and enforcement efforts to protect people who rely on healthcare programs and the people who pay for them.  The Work Plan is revised and updated each year, as necessary, to ensure that the OIG oversight operations remain relevant, timely, and responsive.

The OIG Work Plan 2016 expanded the focus on delivery system reform, effectiveness of alternate payment models, coordinated care programs, and value-based purchasing.  The OIG Work Plan 2016 has several  new project review initiatives in place to support the expanded focus. For example:

Medical device credits for replaced medical devices

  • Under this new OIG Work Plan 2016 initiative, the OIG would determine whether Medicare payments for replaced medical devices were made in accordance with Medicare requirements.  Federal regulations require reductions in Medicare payments for the replacement of implanted devices.  Prior reviews have determined that improper payments have been made to hospitals for inpatient and outpatient claims for replaced medical devices.

Increased billing for prolonged E and M Services

  • Under the new  OIG Work Plan 2016, the OIG would study whether Medicare payments to physicians for prolonged evaluation and management (E/M) services were reasonable and made in accordance with Medicare requirements.  The necessity of prolonged services are considered to be rare and unusual by CMS.  The Medicare Claims Process (MCP) manual includes requirements that must be met in order to bill a prolonged E/M service code.

Recoveries for violations

Violations can be costly for instances of inappropriate prolonged evaluations for E/M services or erroneous billing for replaced medical devices. For 2015, expected recoveries were reported to be more than $3 billion, consisting of nearly $1.13 billion in audit receivables and about $2.22 billion in investigative receivables, including about $286.6 million in non-HHS investigative receivables resulting from Medicaid restitution.

These violations can be minimized by maintaining an effective compliance program, utilizing the guidance of the OIG.  An effective compliance program can strengthen the efforts of your healthcare facility to prevent and reduce improper conduct, and help streamline business operations.

Become familiar with the OIG Work Plan 2016

As we have in the past, we encourage our physician practices, hospitals, skilled nursing and other health care clients to renew their commitment to an active and dynamic compliance program.  Further, take the time to learn more about the OIG  Work Plan 2016 by reviewing our OIG Work Plan blogs.  Doing so should trigger a review and update of your organization’s healthcare compliance program.

When you need proven expertise and performance

Cindy Winn, MBA, CHSP

Ms. Cindy Winn has over 20 years of healthcare experience and expertise in operations, project management, and is certified as a HIPAA Security Professional (CHSP).

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