Office of Inspector General Work Plan 2015: A Provider's Overview-Part 1

Friday, November 21, 2014
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Michael L. Smith, R.R.T., J.D., Board Certified by The Florida Bar in Health Law

Each new fiscal year, the Office of the Inspector General (OIG) Department of Health and Human Services (HHS) releases its annual Work Plan.  This Work Plan is the general overview of how the OIG intends to carry out its mission to make the Medicare and Medicaid programs run more smoothly and efficiently in the following year.

A large part of what the OIG does is review and investigate Medicare claims for overpayment.  The Work Plan allows the public to see how exactly the OIG plans to utilize its resources in enforcing Medicare and Medicaid regulations.

Of particular importance to Medicare and Medicaid providers is the Work Plan's detailing of particular areas and billing codes and practices that will be under additional scrutiny during the 2014-2015 fiscal year.  By knowing where the enforcement focus will be, providers can attempt to avoid practices that are likely to lead to audits and investigations.  Additionally, a provider that is in a high-focus area can prepare for potential audits by beefing up its documentation and compliance efforts.

To read the entire 90-page document, click here. If you don't have that kind of time, read on for an overview of the 2015 Work Plan.


The OIG will focus on 22 substantive areas within hospitals. Most of these areas focus on Medicare billing compliance, ensuring hospitals are receiving correct reimbursements, and monitoring the quality of care provided to patients. The OIG will also study the effects of the "two midnight" rule for establishing inpatient vs. outpatient status.

In addition, the OIG is looking to put an emphasis on the investigation of outpatient dental claims. Past audits have indicated that hospitals received Medicare reimbursements for non-covered dental services, resulting in over-payments. Dental services are usually excluded from Medicare coverage, with limited exceptions.

Nursing Homes/Skilled Nursing Facilities

Nursing homes and skilled nursing facilities (SNFs) are a large source of abused federal healthcare dollars. As such, Work Plan 2015 has several key areas that will be the focus of OIG action.

Illegal Billing Practices

Through audits the OIG hopes to identify illegal billing patterns associated with nursing     homes and Medicare providers for services provided to nursing home and SNF patients. In particular, these institutions are notorious for unnecessarily billing at the highest level of therapy.

Verification of Deficiency Correction

The OIG plans to verify compliance with deficiency corrections that are required by state     survey agencies.  This means that not promptly and completely correcting deficiencies cited by a state agency can impact a facility's ability to bill Medicare.

Hospitalization of Patients

The OIG plans to determine the extent to which Medicare beneficiaries residing in nursing     homes and SNFs are hospitalized as a result of conditions thought to be manageable or preventable. The hospitalization of nursing home residents is costly to Medicare and may indicate quality-of-care problems in nursing homes and SNFs.


Hospices need to review the extent of services provided to Medicare beneficiaries who live in assisted living facilities (ALFs). The OIG will check on the length of stay, level of care received and common terminal illnesses of beneficiaries who receive hospice care in ALFs.

The OIG will review hospices' inpatient care claims to address abuse concerns. Hospice medical records will also be reviewed to determine if the level of hospice care is being misused.

If you are an ALF, nursing facility or hospice provider it is highly advised that you thoroughly review your eligibility determinations and supporting documentation as this is likely to be a highly audited area.

Home Health Services

Because of the nature of the home health service business, it is difficult to monitor and evaluate the business practices.  A review of the 2015 Work Plan reveals that the OIG will continue to focus on compliance in this area, including the documentation required to support the claims paid by Medicare. A prior OIG report found that one in four home health agencies had questionable billing. Furthermore, newly enrolling home health agencies (HHAs) are designated as high-risk providers, citing their history of fraud, waste, and abuse.

The OIG will also investigate whether or not HHAs are complying with requirements for criminal background checks of employees. If you employ disqualified employees, you could possibly face claim denials, a state license action against your facility, or termination of your Medicare or Medicaid billing numbers.

Medical Equipment and Suppliers

Another high-fraud area is medical equipment and supplies. As such, a number of new and continuing processes will be implemented in 2015 by the OIG to ensure the integrity of Medicare and Medicaid payments to medical equipment suppliers.

Power Mobility Devices

The OIG will determine whether potential savings can be achieved by Medicare if certain     power mobility devices (PMDs) are rented rather than acquired through a lump-sum purchase. The OIG will also be reviewing claims for medical necessity related to PMDs.

Lower Limb Prostheses

The OIG plans to increase its review of claims for lower limb prostheses due to high dollar     individual claims that are a particularly fertile area for billing fraud. Previously, the OIG’s investigations have discovered a high number of prostheses claims that are billed with no physician order, no patient history of amputation, and other questionable billing characteristics. If you bill for these items, or any other big-ticket equipment, be sure that you have all of the documentation to support the necessity of the claim.

Frequently Replaced Supplies

The OIG is going to continue to review claims of supplies that are often replaced to ensure     that the supplier is not automatically refilling.  The Work Plan states that diabetes testing supplies are going to be a main area of focus.


New to the list this year is a review of independent clinical laboratory billing requirements. However, the Work Plan did not specify what billing requirements were at issue. This may coincide with increased local coverage determinations by contractors, OIG enforcement against clinical laboratories under its Civil Monetary Penalties Law authority, and OIG's general heightened scrutiny of billing and payment compliance by clinical laboratories, especially specialty laboratories.

Still Want to Know More?

The 2015 Work Plan is full of insider information on that's important for health care providers, professionals, and facilities to understand. Be sure to check this blog regularly for part two. In it, we will cover topics including EHR incentive payments, Medicaid payments, and how all this will affect you.

Contact Health Law Attorneys Experienced in Handling OIG Actions.

Whether you, your company, or a colleague is looking for a review of your compliance processes or is facing an audit, a fraud control unit investigation, or other state or federal OIG action, it is imperative that you contact a health law attorney who has experience dealing with those matters.

The Health Law Firm routinely represents providers of all kinds in these actions and is capable of assisting your practice.  We have developed relationships with recognized experts in healthcare accounting, healthcare financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at

About the Authors: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Michael L. Smith, R.R.T., J.D., is Board Certified by The Florida Bar in Health Law. He is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Tag Words: OIG, Office of the Inspector General, CMS, Centers for Medicare and Medicaid Services, Work Plan 2015, audit, enforcement, HEAT, Medicare, Medicaid, LEIE, List of Excluded Individuals and Entities, Medicare Fraud Strike Force, home health, Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC), fraud, claim review, defense attorney, defense lawyer

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1999-2014 The Health Law Firm. All rights reserved.
George F. Indest III and Michael L. Smith 11/21/2014

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