January 5, 2017

OIG Work Plan for 2017

By Marilyn Mines, Senior Manager, Advisory Services, Bonny Kohr, Senior Manager, Advisory Services & Janet Potter, Senior Manager, Advisory Services

OIG Work Plan for 2017

The annual Office of Inspector General (OIG) work plan was released on November 10, 2016. If you haven’t already done so, it is time to begin preparing your organization for potential OIG or other audits. Corporate compliance programs and self-audit activities should be ongoing and reviewed and updated periodically. The OIG Work Plan is an excellent tool for all providers to use to determine which areas of their specialties are vulnerable to fraud and abuse and more likely to trigger an audit. This article will explore various areas that the OIG has on its radar for 2017. As always, the OIG is focusing on fraud, compliance, oversight and quality of care.

Nursing Facilities

Since some state survey agencies have not acted quickly on complaints that may be immediate jeopardy or actual harm, the OIG is taking a closer look at timeline requirements by the states. By regulation, these types of complaints must be reviewed within 2 days for immediate jeopardy and 10 days for actual harm from when they were reported. In a related item, the OIG will also be looking for evidence that residents in the SNF may have incidents of abuse and/or neglect that were not reported or properly investigated. To accomplish this, the OIG will interview state surveyors and officials regarding selected incidents to determine if the incidents were reported, investigated, and prosecuted as appropriate in each case.

Per the OIG, SNFs continue to bill for higher levels of therapy than are needed or administered. Documentation will remain the focus of attention to ensure that all therapy RUG categories that are reimbursed, meet the regulations for medical necessity and have actually been provided. In this new area of review, activities of daily living will also be audited to ensure they are accurate.

Some continued areas of focus include adverse events and employee background checks. A tool to report and analyze adverse events in the SNF was developed in 2014, the OIG will promote this tool and help SNF providers to understand how to utilize it. The OIG will review the background checks on prospective employees with direct access to residents, to determine whether the program outcomes were appropriate.

The issue of admission to a SNF without a 3-day inpatient hospital stay or within 30 days of discharge from that stay, continues to be questioned. The OIG FY 2017 work plan will continue to analyze data and review compliance with this requirement. This year the OIG will be reviewing readmissions to hospitals for potentially preventable conditions, as well as for identifying whether the hospitalization was necessary, or could be treated in the SNF setting. This item also refers to whether the interventions in the screening residents’ plan of care are being implemented.

Since the OIG believes that transfers from the nursing facility to the hospital are an indication of poor quality of care, this year’s review will include transfers from nursing homes to hospital emergency rooms and group homes.

The OIG will be investigating whether state survey agencies actually verify that all plans of correction have been made. This item arose from the identification of one agency which did not do so. The OIG’s intent is to determine how wide spread this situation is. This verification of the completed plan of correction is either done during a revisit, or through other evidence.

The OIG will review state tax programs not only for hospitals, but also nursing homes to determine if hold-harmless requirements are being met as they relate to Medicaid MCOs.

Please note, skilled nursing facilities should also be aware of the review of DME in a non-Part A stay detailed in the section on Durable Medical Equipment.


The OIG has identified areas in the hospice program that they believe are vulnerable and may have a negative impact to beneficiaries and the program. The areas include payment, compliance, oversight and quality of care. Based on their findings the OIG plans to provide recommendations for protecting beneficiaries and improving the program in FY 2017. The OIG plans to focus their work on the following areas.

The OIG plans to conduct reviews to determine if registered nurses made required on-site visits to the homes of Medicare hospice beneficiaries at least once every 14 days.

OIG plans to review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements.

Home Health Agencies

During on-site surveys for Medicare certification Home Health Agencies (HHAs) must provide the Centers for Medicare and Medicaid Services (CMS) and state surveyors with a patient list and schedule of visits. OIG expressed concern that fraudulent HHAs might omit certain patients from the patient lists and schedules provided. The surveyors do not have access to Medicare claims data to verify patients receiving Medicare services and the OIG states that they “will determine whether HHAs are accurately providing patient information to State agencies for recertification surveys.” The OIG work plan does not reveal the method that the OIG plans to use to make this determination.

As a result of the OIG reports continuing to identify improper payments to HHAs for beneficiaries who are not homebound or who did not require skilled services they also plan to conduct further medical review of home health documentation for compliance with federal requirements. The Comprehensive Error Rate Testing (CERT) program determined that in 2014 the improper payment rate for home health agency services is over 51%.

Durable Medical Equipment

A new item for review and audit, is reviewing Part B DMEPOS claims for residents in a SNF (non-Part A). Only therapy and certain supplies are actually billable to the Medicare program for individuals residing in an institution, not DMEPOS items. The goal is to determine if there is a process in place to identify these charges and the ability to recoup the payments.

There will also be an activity to determine that all DMEPOS is ordered by a physician or non-physician practitioner (NPP). Claims for items not ordered by a physician or NPP who is not eligible to order or refer are not eligible for payment by Medicare.


The OIG will review Medicare payments for both transitional care management (TCM) and chronic care management (CCM) services. Both programs have specific guidelines and restrictions and the OIG wants to ensure those are being followed.

The OIG will also review claims for home visits as well as prolonged services for reasonableness and medical necessity. In both situations the evaluation and management services must meet Medicare guidelines in order to be payable by Medicare.

As in past years, the OIG will review claims to Medicare Part B for chiropractic services to ensure that they are reasonable and medically necessary, as well as properly documented. Chiropractic maintenance therapy is not considered medically necessary and claims for such will be denied. Previous reviews by the OIG have uncovered chiropractic services which were not medically necessary and fraudulent.

Medicare services may not be paid for claims for beneficiaries who are deceased. The OIG will investigate physician claims and other provider’s claims for services presumably rendered to deceased beneficiaries. These will include not only fee-for-service Medicare, but Medicare Advantage and Medicare Part D. The OIG will also review claims for beneficiaries who are incarcerated because generally Medicare does not pay for services for those who are incarcerated.

Medicaid Home and Community-Based Service (HCBS)

OIG plans to issue a data brief that provides an overview of data collected from 50 State Medicaid Fraud Control Units and OIG’s Office of Investigation. The OIG reports that the data shows a high prevalence of fraud and patient abuse and/or neglect with personal care services. Prior OIG work indicated that payments for adult day health care services and room-and-board costs associated with HCBS waiver programs do not always comply with Federal and State requirements. The OIG will review Medicaid waiver programs to determine if the waivers are efficient, economic, and do not inflate federal costs. In addition to conducting reviews of the waiver programs the OIG plans to look at CMS’ oversight of state Medicaid waivers.

Other Providers and Programs

Laboratory: A mandatory review of the top 25 lab tests will be conducted to identify and implement a new payment methodology.

Ambulance Services: The OIG will examine claims for ambulance services to determine if they are in accordance with Medicare requirements for coverage. In particular, they will examine those services for advanced life support and emergency transports.

Medicaid Transportation Services: Although each state Medicaid program can determine coverage criteria and reimbursement rate, the needed transportation for Medicaid beneficiaries must be provided. The OIG will determine the appropriateness of the payment to providers in all states.

Inpatient Rehabilitation Facilities (IRFs): The OIG will conduct a nationwide review of IRFs to determine if the Medicare documentation supports the coverage requirements. They have previously reviewed individual IRFs and found many Medicare overpayments.

Physical Therapy: The OIG will review outpatient physical therapy provided by independent therapists to determine if the services are in compliance with Medicare regulations. Previous reviews have found that the services were not properly documented or not medically necessary.

Portable X-Ray: This is a continued activity to identify the payment for more than one visit to a nursing facility in one day. Included in this concern is an analysis of the qualifications of the technicians being used for this task. Electronic Health Records (EHR): The OIG will be monitoring the use of EHRs for those providers who participate in accountable care organizations (ACOs).

Medicaid Managed Care: The OIG will review state Medicaid managed care programs to determine if their payments for long term care supports is appropriate and conform with federal and state requirements. They will also review managed care organizations to ensure that they appropriately reimbursed providers for services rendered.

The OIG work plan consists of many varied areas in which providers may be subject to an audit or review. Continual review of your program and documentation will help ensure preparedness for the OIG or other auditing body to conduct their own audit. At Marcum, we can provide assistance with reviewing your documentation, training your staff, and performing a mock audit. Contact your Marcum advisor for more information.

Information contained herein is accurate at the time of publication. We recommend that you consult with your Marcum advisor before implementing any action.

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