Kusserow on Compliance: HHS OIG Releases Work Plan for FY 2015

On October 31, 2014, the HHS Office of Inspector General (OIG) issued its fiscal year (FY) 2015 Work Plan. This comes at the beginning of the FY, which began October 1, 2014. The 2015 Work Plan was released three months earlier than last year’s, which was not done until January 31, 2014, into the second quarter of the FY. This posting will provide a quick look at the Plan and will be followed by more detailed analysis of various sections in following postings. The Work Plan is part of the OIG oversight of more than 300 programs, although an extensive amount of effort and resources are focused on the Medicare and Medicaid programs and their beneficiaries. The OIG operates through four major divisions: Office Audit, Office Evaluation and Inspection, Office of Investigations, and Office of Counsel to the IG. The first two represent the bulk of the plan in that they provide information about intended areas of work, whereas the investigators and attorneys primarily respond to legal issues as the arise, although the Work Plan speaks to several initiatives that involve these functions.

Accomplishments Reported

  • Expected recoveries of $4.9 billion, including $4.1 investigative receivables (of which $1.1 were Medicaid) and $845 million audit receivables
  • $15.7 billion in estimated savings as result of actions taken on prior OIG recommendations
  • Over $5.8 billion in investigative receivables
  • 4,016 individuals and entities excluded from participation in federal healthcare programs
  • 971 criminal actions taken against individuals or entities (crimes against HHS programs)
  • 533 civil actions, which include false claims and unjust-enrichment lawsuits and others

Quick Glance at the Work Plan

The Work Plan outlines new and continuing OIG operations and reviews. Most of work plan items reflect continuation of work previously reported in prior plans. New items are denoted by “(New)” after the project title. New projects are followed by the year the project will begin, and a report may be issued in the same year or the following year. Ongoing projects are followed by the year a report is expected to be issued. For each planned review, the OIG provides: (1) an internal identification code; (2) the year in which the OIG expects to issue results; (3) information as to whether the work is a continued or a new focus. The OIG posts all issued reports to its website.

As expected, the OIG will continue include to review entities, including hospitals, nursing homes, hospice, and home health services. Examples of Work Plan items for FY 2015 include:

  • New inpatient admission criteria;
  • Medicare oversight of provider-based status;
  • Duplicate graduate medical education payments;
  • Outpatient evaluation and management services billed at the new-patient rate;
  • Oversight of hospital privileging;
  • Questionable billing patterns for Part B services during nursing home stays;
  • Hospice general inpatient care;
  • Home health prospective payment system requirements;
  • Diagnostic radiology-medical necessity of high-cost tests; and
  • Selected independent clinical laboratory billing requirements.

It is the intention of the OIG, as part of its policy of open transparency, to let everyone know about its plans. The OIG does this so that individuals and entities will be able to review the Work Plan and use it to compare issues identified by the OIG to their own organization. This will allow time to help everyone “bring their house” in better order. As such, all those entities that are involved in HHS programs should examine the OIG Work Plan and review risk areas related to their areas of operation so as to permit, where needed, corrective actions to avoid OIG enforcement actions.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.