OIG Annual Work Plan for 2016 Series: Spotlight on OIG Investigations and Affordable Care Act Review Part Two of Two

Friday, November 20, 2015
By Michelle Bedoya and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law.

The United States Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its 2016 Annual Work Plan (Work Plan) on November 2, 2015, with an effective date of October 1, 2015. The 2016 Work Plan identifies the new and ongoing investigative, enforcement and compliance activities that the OIG will undertake. Through the Work Plan, a broad range of focus areas were revealed that indicate where the agency will concentrate its investigative resources. In addition to the key focus areas listed in part one of this blog series, part two will outline the OIG's legal and investigative activities as well as, its review and oversight of Affordable Care Act program implementation.

Past Enforcement Initiatives.      

Unwavering with its mission to detect fraud, waste and abuse, the OIG has reported expected recoveries of more than $3 billion and has excluded 4,112 individuals and entities from participation in federal health care programs in the last year alone. Through it's Medicare Fraud Strike Force Teams, the OIG has touted about shutting down health care fraud schemes around the country, arresting thousands of criminals and recovering millions of taxpayer dollars.

Stay Ahead: The Best Defense is a Good Offense.

After reviewing the Work Plan, providers should develop or update their compliance plans in accordance with the OIG's priorities. The Work Plan is a tool to guide providers’ compliance efforts both now and in the future.

The Work Plan spotlights the following key focus areas:

CMS Related Legal and Investigative Activities.

In order to combat fraud, the Work Plan indicates that the OIG will use its authority to pursue cases related to Civil Monetary Penalties (CMP), the False Claims Act (FCA) and the Anti-Kickback Statute (AKS). More specifically, cases relating to:

1.    controlled and non-controlled prescription drugs;
2.    home health agencies, personal care, and home and community based services;
3.    ambulance transportation;
4.    durable medical equipment; and
5.    diagnostic radiology and laboratory testing.

The Work Plan further outlines the OIG’s response to requests for formal advisory opinions on applying the AKS and other fraud and abuse statutes to specific situations. To foster compliance by providers and industry groups, the Work Plan provides advisory opinions, which deliver meaningful guidance on statutes in specific factual situations. For examples of these advisory opinions, click here.

Affordable Care Act Reviews.  

In an effort to ensure that such programs meet the aims of providing access to health insurance, improving quality of and access to healthcare and lowering healthcare costs, the Work Plan provides for broad oversight of Affordable Care Act programs. The OIG will assess implementation and operation of Affordable Care Act programs as well as progress toward achieving program goals in three prioritized areas:

1.    the health insurance marketplaces;
2.    Medicare and Medicaid reforms; and
3.    grant expenditures for public health programs.
In addition to the specific areas of focus set forth, the Work Plan states that OIG will initiate additional reviews addressing Affordable Care Act programs. The reviews could focus on a range of topics, including:        

1.    emerging marketplace issues;
2.    Medicaid expansion;
3.    Medicare payment and delivery models; or
4.    program integrity.

Recovery Act Reviews.

The Work Plan includes the OIG's continuing initiatives to monitor oversight of the agency’s use of American Recovery and Reinvestment Act of 2009 funds. The initiatives are as follows:
1.    Adoption of Electronic Health Records.             

a.    The OIG will review Medicare and Medicaid incentive payments to eligible health care professionals and hospitals adopting electronic health records to identify providers that should not have received incentive payments.

2.    Systems and Information Security.

a.    In addition, the OIG will audit various covered entities receiving eligible health care incentive payments to determine whether those entities are adequately protecting electronic health information.

3.    Fraud and Whistleblower Reprisals.

a.    In order to evaluate credible allegations of improper expenditures of Recovery Act funds and credible allegations of reprisals against whistleblowers, the OIG will continue to identify cases in which criminal investigations should be opened and enforcement actions pursued.


The newly enacted Bipartisan Budget Act of 2015 will increase CMP under both the FCA and the Civil Monetary Penalties Law. Now, more than ever, it is critical for providers to ensure that they are in compliance with the many governing rules and regulations.

For a complete outline of all ongoing focus areas, read the 2016 OIG Work Plan here

Still Want to Know More?

The 2016 Work Plan is full of insider information on important topics for health care providers, professionals and facilities to understand.This blog series serves as an overview of the OIG's initiatives and focus areas in the upcoming year.

Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620.


"Work Plan Fiscal Year 2016."  U.S. Department of Health and Human Services: Office of Inspector General, 2015.

Edwards, Susan.  "Bipartisan Budget Act jacks up civil monetary penalties under the Social Security Act and False Claims Act penalties." Health Industry Washington Watch. Reed Smith LLP.. 11 Nov. 2015. Web. 18 Nov. 2015.

About the Author: Michelle Bedoya is a long-time consultant to home health agencies and is currently a student at Barry University School of Law. 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.  www.TheHealthLawFirm.com. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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“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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