The OIG Work Plan: What Is It and Why Should I Care?

by  NAMAS
Aug 9th, 2019

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.

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]