The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within the U.S. government system. Most of OIG's resources go towards overseeing the Medicare and Medicaid programs, mostly through a nationwide network of audits, investigations, and evaluations in an effort to promote cost savings and make policy recommendations. Additionally, OIG assists in the development of cases for criminal, civil, and administrative enforcement agencies.
In 2018 alone, "investigations conducted by HHS-OIG resulted in 679 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 795 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties ('CMP') settlements, and administrative recoveries related to provider self-disclosure." [ 1] These investigations and disclosures resulted in over $2.3 billion in healthcare fraud judgments and settlements. These numbers have been increasing every year and financial recovery of alleged overpayments has become a huge and lucrative business for the contractors selected by the government to conduct provider audits.
Healthcare providers, organizations, compliance officers, and auditors should all keep abreast of the OIG's audit targeting process by following the OIG's Work Plan. In its own words, the OIG Work Plan "sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections." [2] The OIG plans its work by assessing relative risks in various HHS programs and operations to identify areas it believes are in need of audit scrutiny. Once that's done, priorities are set for the sequence and proportion of resources to be allocated. The work portfolio also includes several legal and investigative activities.
The OIG's Active Work Plan Items can be found at https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp. An item recently added to the work plan which impacts several of my personal clients was announced in June 2019 and is titled "Review of Medicare Part B Claims for Intravitreal Injections of Eylea and Lucentis." This work plan item specifically pertains to ophthalmology practices and, if you click on the item in the work plan, you can find more information on what the OIG is specifically targeting. In this case, it states that "[OIG] will review claims for intravitreal injections of Eylea and/or Lucentis and the other services billed on the same day as the injection, including evaluation and management services, to determine whether the services were reasonable and necessary and met Medicare requirements." [3]
The work plan is updated monthly and it "will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work." For anyone involved in healthcare, whether a provider or an auditor, it's always good to have your finger on the pulse of what items and areas the government is actively auditing and investigating. If you're not doing it already, the OIG Work Plan is a good resource and is worth a bookmark in your Internet browser.
