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We Defend Healthcare Providers Nationwide in Audits & Investigations

The OIG 2014 Work Plan Has Been Released

(February 3, 2014): Last month, the U.S. Department of Health and Human Services, Office of Inspector General (OIG) released its 2014 Work Plan. The OIG 2014 Work Plan can serve as a virtual “heads-up” for health care providers, durable medical equipment (DME) suppliers, and third-party billing companies seeking to remain aware of the likely areas of enforcement where OIG will be dedicating its audit and investigative resources in the upcoming year.  Health care providers, suppliers, and billers seeking to remain compliant with Medicare and Medicaid program requirements can get a much clearer picture  of the government’s most recent list of concerns. The OIG invests significant time and resources in its efforts to recover monies that have been improperly billed to government programs. Moreover, the agency aggressively pursues individuals and entities that engage in fraud, waste, or abuse of Medicare program resources.  In addition to levying Civil Monetary Penalties (CMPs) for program integrity violations, the OIG also has the authority to exclude a provider or supplier from participating in federal health care programs for a variety of reasons (most of which involve the violation of a particular statutory or regulatory provision).  Financially, the OIG reports that it recovered the following in Fiscal Year (FY) 2013:

…we reported expected recoveries of over $5.8 billion consisting of nearly $850 million in audit receivables and about $5 billion in investigative receivables, which include about $1 billion in non-HHS investigative receivables resulting from our work in areas such as the States’ shares of Medicaid restitution.

The OIG also reported the following for FY 2013:

  • Exclusion of 3,214 individuals and entities from participation in Federal health care programs;
  • 960 criminal actions against individuals or entities that engaged in crimes against HHS programs; and
  • 472 civil actions  against individuals and entities.

Various topics remain of heightened concern to OIG, including evaluation and management (E/M) services and credentialing and quality of individuals working across all medical fields. In regard to the former, E/M services, a new review has been planned for the billing of outpatient E/M services at the new-patient rates in the hospital setting. If a patient has been seen in a hospital within the past three years, the patient is considered “established” pursuant to federal regulations. Preliminary findings by OIG, however, show that hospitals use new patient codes when billing services for established patients. There is also a general ongoing review to ensure that E/M services selected by providers are supported by the submitted documentation.

As for employee quality control, there are numerous new and ongoing reviews on the OIG’s agenda. The areas and topics include:

  • Hospital participation in projects with quality improvement organizations;
  • National background checks for long-term-care employees in nursing homes;
  • Employment of individuals with criminal convictions in the home health setting; and
  • Medicare enrollment and credentialing of mental health providers.

We encourage our health care provider, supplier, and biller clients to carefully review the OIG 2014 Work Plan. An understanding of the OIG’s focus areas will help providers, suppliers, and billers to avoid audits and ensure ongoing compliance with government health care program requirements.

Healthcare LawyerLorraine Ater, Esq. is a health law attorney with the boutique firm, Liles Parker, Attorneys & Counselors at Law.  Liles Parker has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Our attorneys represent health care professionals around the country in connection with government audits of Medicaid and Medicare claims, licensure matters and transactional projects.  Need assistance?  For a free consultation, please call: 1 (800) 475-1906.



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