OIG Workplan Tips

Mary Beth Black,
MBA, MHA, CPC, CEMC, CPMA
Senior Associate

2015 OIG Work Plan Update: Each year the Office of Inspector General (OIG) publishes its Work Plan. The Work Plan is comprehensive and encompasses Medicare Part A and Part B, Medicare Part C and Part D, as well as the Medicaid Program, CMS-Related Legal and Investigative Activities, Public Health Reviews, Human Services Reviews and Other HHS-Related Reviews.

For our purposes, we will focus on a few areas that affect physician practices. The following are just some of the areas that the OIG will be reviewing that will result in challenges to physician practices:

1. Physicians - Place-of-Service Coding (POS) Errors
   • The OIG will review POS codes to ensure that providers are not being overpaid when they provide services in a location other than their office.
   • Professional reimbursement is lower when services are provided in a hospital or outpatient clinic, because the provider has less overhead.
   • Prior OIG reviews indicated that providers did not always use the proper POS code, which resulted in overpayments.
2. Exclusions from Program Participation, False Claims, Criminal and Civil Penalties
   • There are many reasons why the OIG can and will exclude a person or entity from participation in Federal programs.
   • The OIG has experienced an increase in program-related convictions. These include: patient abuse/neglect, licensing board disciplinary actions or other actions that pose a risk to beneficiaries or programs.
   • The OIG can levy civil penalties when it finds evidence of false or fraudulent claims, kickbacks or remuneration in violation of the Social Security Act.
   • The OIG can levy criminal penalties when it finds evidence of fraud, waste or abuse, which can lead to hefty prison sentences and monetary fines. The OIG works with the Federal Bureau of Investigation, the U.S. Postal Inspection Service, the Internal Revenue Service and State Medicaid Fraud Control Units, among other organizations.

Be aware that the above list is not all inclusive. However, the items listed have been on the OIG's radar for a few years. You should consider many of these items to be ongoing. Compliance is still extremely important to the success of your practice in avoiding complications with the OIG. For additional information and the complete OIG Work Plan, refer to https://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf.

If you have any questions, contact Mary Beth Black, Senior Associate, at 770-951-8427 or mbb@medicalmanagement.com.