2016 OIG Work Plan

by Nicole Almiro


The Department of Health and Human Services Office of the Inspector General recently released its 2016 Work Plan. OIG’s annual Work Plan summarizes new and ongoing reviews and activities that the OIG plans to pursue with respect to HHS programs and operations during the current year and beyond.We should all carefully review the OIG Work Plan, understand the OIG’s areas of focus and ensure that we are in compliance with the applicable statutes and regulations. Below are a few of the issues from this year’s work plan I thought was applicable. Please contact Compliance with any questions or concerns.


  • Provider-Based Facilities: The OIG continues to review the extent to which provider-based facilities meet the provider-based criteria as established by CMS. In addition, the OIG plans to continue to review and compare Medicare payments for physician office visits in provider-based facilities and freestanding clinics to determine the potential impact on the Medicare program and whether the payment differential is justified.
  • Replaced Medical Devices: The OIG will determine whether Medicare payments for replaced medical devices were made in accordance with Medicare requirements. Per federal regulations, the replacement of implanted devices requires reductions in Medicare payments, and prior OIG reviews have determined that MACs have made improper payments to hospitals for inpatient and outpatient claims for replaced medical devices.
  • Outpatient E&M Codes: The OIG intends to review Medicare outpatient payments for E&M services to determine whether such services were appropriately coded as “new” or “established.” The OIG stated that overpayments have occurred as a result of hospitals indicating that a patient was “new” when the patient should have been coded as “established” under the federal regulations.
  • End Stage Renal Disease (ESRD) Bundles Payments: The OIG will continue to analyze payments for ESRD services and drugs under its bundled prospective payment system (PPS) rate.
  • Anesthesia Services- Payment for Personally Performed Services: The OIG will continue its efforts to investigate Medicare Part B claims for personally performed anesthesia services (service code AA) to determine whether such claims are supported in accordance with Medicare requirements. The OIG noted again that personally performed services are billed at a rate double that of services performed under an anesthesiologist’s medical direction (service code QK), and that incorrect coding results in Medicare paying a higher amount. Anesthesiologists working with nurse anesthetists should ensure that they have proper documentation for all services personally performed (AA), but should use the QK modifier if the patient is left in the care of a nurse anesthetist at any time.
  • Portable X-ray Equipment: The OIG plans to continue its assessment of qualifications of technologists that performed portable x-ray services and will continue its review of documentation used to seek Medicare reimbursement.
  • Medicare Payments During MS-DRG Payment Window: The OIG will determine whether Part B outpatient claims for services provided during inpatient stays are allowable.