The Department of Health and Human Services Office of Inspector General (HHS-OIG) recently released its FY 2016 Work Plan, in which it identified key areas of focus for the upcoming year. Consistent with its mandate to detect fraud, waste, and abuse, and to hold accountable those who do not meet program requirements or who violate Federal health care laws, the OIG’s Work Plan outlines several enforcement initiatives. As a result of the its enforcement initiatives in FY 2015, the OIG excluded over 4,000 individuals and entities from Federal health care program participation and expects to recover over $3 billion in Federal health care program payments. The 2016 Work Plan runs the gamut of the healthcare industry and offers providers a valuable tool for staying ahead of OIG’s enforcement and recovery initiatives.

What Providers Should Know

OIG’s FY 2016 Work Plan makes clear that OIG remains committed to ensuring that Federal health care program funds are appropriately used and are recouped where necessary. The OIG conducts audits, evaluations, and investigations to uncover instances of health care fraud and abuse and can impose civil monetary penalties (CMP) where appropriate. Given that CMPs under both the FCA and the Civil Monetary Penalties Law are set to increase by virtue of the newly enacted Bipartisan Budget Act of 2015, it is more important than ever for providers to ensure that they are in compliance with the multitudinous rules and regulations governing the provision of health care services. Health care providers should use the Work Plan as a tool to guide their compliance efforts both now and in the future.

What’s New in FY 2016

For the upcoming fiscal year, the OIG added many new or revised areas of focus. The corresponding FY 2016 audits, evaluations, and investigations will inevitably affect a wide range of providers, though to varying degrees. The following is a sampling of the OIG’s new or revised concerns and plans, identified by provider or service type:

• Hospitals

• Nursing homes

• Therapy billing

• Hospice

• Physicians

• Accountable Care Organizations (ACOs)

• Pharmacies

• Medical Equipment & Supplies

• Prescription Drugs

• All Providers

What’s Still a Priority

Many areas of focus in years past remain a priority for OIG in FY 2016. Overall, OIG continues to focus on identifying improper and/or fraudulent claims for services that were not medically necessary. In FY 2016, the OIG plans specifically to continue its enforcement efforts on the following:

• Hospitals

• Home health

• DMEPOS Suppliers

• End Stage Renal Disease (ESRD) Facilities

• Laboratories

• Nursing homes

• Medicaid Program Integrity at the State Level

Payment suspensions following a credible allegation of fraud are required by state Medicaid programs unless the program affirmatively determines that a payment suspension could have an adverse effect on an investigation or on Medicaid beneficiaries. Not all states have robustly implemented this rule, but are likely to do so following publication of the 2016 Work Plan. Providers should educate AR staff on the possibility of payment suspensions so they can respond quickly and effectively.

To view or download the full PDF, click here.