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Reading the Tea Leaves: Understanding OIG Priorities


Reading the Tea Leaves: Understanding OIG Priorities

The Office of Inspector General of the U.S. Department of Health and Human Services (“OIG”) issues work plans (“Work Plan”) that addresses priority areas and emerging issues. For many years, the OIG published its Work Plan every two years with intermediate updates published once or twice each calendar year. Beginning on June 15, 2017, however, the OIG changed its practice and publishes the Work Plan on a monthly basis. These monthly updates are published through the OIG’s Work Plan website.

The format and structure of the Work Plan also changed; updates are no longer organized by agency or subject matter. Instead, the Work Plan projects are published individually, organized by date and vary in number from month-to-month. For example, the OIG published 12 new projects in June, seven in July, and 11 in August.

Although the OIG is responsible for oversight of all constituent agencies of the U.S. Department of Health and Human Services (“DHHS”) a significant majority of these projects involve Centers for Medicare and Medicaid Services (“CMS”) programs. Examples of a few recent items/projects include:

August 2018

  • CMS Oversight of Nursing Facility Staffing Levels
    • OIG plans to examine nursing staffing levels reported by facilities to CMS and CMS’s efforts to ensure data accuracy and improve resident quality of care by both enforcing minimum requirements and incentivizing high-quality staffing above minimum requirements.
  • Physicians Billing for Critical Care Evaluation and Management Services
    • Reimbursement for critical care is time-based and depends upon the number of minutes a physician spends with the patient. OIG plans to examine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.

July 2018

  • Health Resources and Services Administration's (“HRSA’s”) Oversight of Funds for Access Increases in Mental Health and Substance Abuse Services (AIMS)
    • HRSA awarded $200.5 Million in AIMS grants in 2017 meant to expand access to mental health and substance abuse services. OIG plans to review HRSA's internal controls to determine whether they are suitable for (1) awarding AIMS grants and (2) monitoring AIMS grant recipients.

Understanding the OIG’s enforcement priorities continues to remain important as ever, particularly since the amount of civil monetary penalties (“CMPs”) that can be imposed for violations of Medicare and Medicaid have increased and are now indexed to inflation. The current CMP amounts are available at 45 CFR §102.3 and include:

  • Knowingly filing a false claim: $15,270
  • Anti-Kickback Statute violation: $74,792
  • Medicare Beneficiary Inducement: $15,270
  • Stark Law violation: $24,253
  • Circumvention of the Stark Law prohibition: $161,692

Despite recent changes in structure and format, the OIG Work Plan remains a valuable tool for understanding OIG priorities. Providers should regularly monitor the Work Plans.

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