Office of Inspector General Work Plan 2015: A Provider's Overview-Part 2

Monday, November 24, 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

An ounce of prevention is worth a pound of cure.

Through the 2015 Office of the Inspector General (OIG) Work Plan, the agency has revealed how it plans to carry out its mission to ensure the Medicare and Medicaid programs run more efficiently in the 2015 fiscal year. As a health care provider, knowing the ins and outs of this Work Plan could save you from the headache and possible fines that may come with a Medicare and Medicaid OIG audit. By using the resources in the first part of this blog and the following information, you can beef up your compliance efforts.  

Other Areas of Focus

In addition to the specific industries listed in our first blog, the OIG plans to continue to use the following tactics and methods to ensuring billing integrity.

1.  The OIG will review Medicare incentive payments for adopting electronic health     records (EHRs) and receiving incentive payments based on meeting meaningful use criteria.

2.  The OIG continues to review payment systems, such as provider-based services and freestanding clinic payments, with a goal of reducing disparity of payments based on site of service.

3.  The OIG intends to conduct a risk assessment of CMS' administration of the pioneer Accountable Care Organization model.

4. The OIG will review the appropriateness of Medicare’s methodology for setting ambulatory surgical center (ASC) payment rates under the revised payment system.

5.  Anesthesia services will be reviewed for claims containing "personally performed services." The OIG will also look at claims with the "AA" and "QK" modifiers.

6.  Ambulance and medical transport services will continue to be the subject of frequent audits.

7.  Chiropractic services will be scrutinized for medical necessity, and proper documentation in accordance with Medicare requirements.

8.   Diagnostic radiology claims will also be reviewed for medical necessity as well as for duplicate testing ordered by primary care physicians and specialists.

9.  Other imaging services claims will be reviewed to determine if the practice expense components and equipment utilization rates are appropriately billed.

10.  Ophthalmological services will be subject to increased scrutiny, particularly claims from 2012.  The OIG plans to conduct its review with a focus on finding geographic "hot spots" for fraud and then focusing additional audits on those areas. Florida, Texas, California, New York, and Ohio physicians should take particular note of this.  As high fraud areas, it is inevitable that increased audits will be coming.

11.  Increased audits will take place regarding outpatient physical therapy services provided by independent therapists.

12.  X-ray equipment services will be investigated to verify payments were made correctly, with supporting documentation. The OIG will also assess the technologists who performed the services.

13.  The OIG will increase audits for sleep study orders and sleep disorder clinics and will examine these entities for improper referral practices and revenue sharing.


Because state Medicaid programs are jointly funded by the federal government, continued review of Medicaid claims for fraud and compliance is planned by the OIG.  The Work Plan states that the following areas, among others, will be reviewed:

1. Home Health Services - beneficiary eligibility, physician determination of a plan of care, and health and background screening of employees;

2.  Adult Day Care - review of necessity, eligibility, and furnishment of services in accordance with a plan of care;

3.  Medical Equipment Suppliers - increased scrutiny of suppliers' billing practices;

4.  Transportation Services - review of necessity and beneficiary eligibility; and

5.  Pediatric Dentistry - billing patterns and abuse.


The 2015 Work Plan also touts the large recoveries made by the OIG in 2014, as well as the number of Medicare exclusions, criminal convictions and civil recoveries for health care fraud in 2014. The report is consistent with the Department of Justice's (DOJ) recent emphasis on prosecuting companies and individuals for fraud.

This Work Plan shows that the OIG is poised to continue rigorous and thorough enforcement efforts in the coming year.  Providers need to be aware of all of the requirements for each and every code billed and need to maintain comprehensive documentation justifying the bill.

As the OIG implements the Work Plan, it's important to realize this outcome could have a significant impact on a healthcare provider's billing and reimbursement. Many providers are already struggling to grasp recent billing changes, so it is reasonable to assume that billing requirements may become even more complex over the next year.


Did you know about this Work Plan? After reading this summary, are you planning on improving your billing procedures? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced in Handling OIG Actions.

The attorneys of The Health Law Firm can assist in any Medicare or Medicaid audits or in any situation involving the areas discussed above.

Whether you, your company, or a professional 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.
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George F. Indest III and Michael L. Smith 11/24/2014

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