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OIG Updates 2015 Work Plan: New Medicare initiatives for hospitals, DMEPOS suppliers, clinical labs, GPOs

June 9, 2015

The OIG issued on May 28, 2015 an update to its 2015 Work Plan which includes several new Medicare initiatives for the OIG’s audit and inspection during the current fiscal year and forecasts broader areas of focus for future fiscal years.

As the health care industry continues to reform its delivery of care models and payment structures, the OIG reaffirmed its continued focus on certain risk areas which pose significant management and performance challenges for HHS, such as those involving emerging payment, eligibility, management, and information technology systems security vulnerabilities in health care reform programs.

As a practical matter, compliance officers rely on the OIG’s Work Plan as a tool to identify topics for future audits. An understanding of the new topics added by the OIG to its current 2015 Work Plan is essential to that process. These new topics further expand the OIG’s focus in several areas which it previously identified as priorities for hospitals, medical equipment suppliers, clinical labs, and GPOs. Some of the key new topics include:

  • Intensity-modulated radiation therapy (IMRT) services provided by hospitals. Prior OIG reviews have identified hospitals that bill incorrectly for these IMRT services by not completing the bill accurately and improperly billing for services performed as part of developing an IMRT plan.
  • Medicare payments for clinical diagnostic laboratory tests, including the top 25 clinical diagnostic laboratory tests as established by Medicare expenditures in 2014. Previous OIG analysis has revealed that Medicare pays more than other insurers for certain high-volume and high-expenditure laboratory tests. As required by the Protecting Access to Medicare Act, beginning in 2017, Medicare will establish payment rates based on private payer rates and the OIG will annually analyze and monitor these expenditures and the new payment system.
  • Compliance with the documentation and coverage requirements for inpatient rehabilitation facility prospective payment system set forth in 42 CFR § 412.622(a)(3) (4) and (5) for discharges on or after January 1, 2010.
  • Use of electronic health records (EHRs) by ACO participating providers in the MSSP program to exchange health information to achieve their care coordination goals, as well as their use of EHRs to identify best practices and challenges toward interoperability. 
  • Analysis of Medicare Part D program billing patterns for commonly abused opioid drugs as well as pharmacy billing trends in 2014. The OIG is seeing a significant increase in Part D fraud and its expanded focus will include prescription drug diversion activities.
  • Several analyses of Medicaid outpatient drug payment programs regarding calculation and reporting of manufacturer rebates.
  • Manufacturers’ and GPOs’ compliance with data reporting requirements and whether the required data for physician and teaching hospital payments (including disclosure of physician payment and physician ownership information) is accurately and completely displayed in the publicly available database.

In total, the 2015 Work Plan update includes 21 new items.