This is the second of a three-part blog series summarizing the fiscal year OIGWP1-300x1542015 work plan of the Office of Inspector General (OIG) for the U.S. Department of Health & Human Services (HHS). The first blog post described the OIG’s planned areas of focus in its oversight of Medicare Part A and Part B services provided in hospitals and other treatment facilities. This post will describe more of the OIG’s plans involving Medicare services as well plans involving Medicaid.


Medicare Medical Equipment and Supplies

The OIG plans to focus on these areas of equipment and supplies policies, practices, billing and payment:

  • Power mobility devices — evaluate rental versus purchase costs, review payments for medical necessity and whether face-to-face examination requirement was met;
  • Review bidding for diabetes testing supplies and other equipment and services;
  • Review claims for lower limb prosthetics, nebulizer machines, and diabetes testing supplies; and
  • Review claims for frequently replaced supplies.


Other Medicare Parts A and B Services

The OIG will also examine or review —

  • Ambulance services, including questionable billing, medical necessity, and proper levels of service;
  • Payments for personally performed anesthesia services and for imaging services;
  • Questionable billing and inappropriate payments for chiropractic services;
  • Medical necessity of diagnostic radiology tests;
  • Clinical laboratories’ billing requirements compliance;
  • Ophthalmologists’ questionable billing;
  • Improper physician place-of-service coding;
  • High usage of outpatient physical therapy services and sleep-testing procedures; and
  • Payments for portable x-ray equipment.


Medicare Payments for Prescription Drugs

OIG’s plans include reviewing —

  • Average drug sales prices versus average manufacturer prices;
  • Potential savings under the 340B program;
  • Payments for some immunosuppressive drugs;
  • Coding for chemotherapy drugs;
  • Covered uses; and
  • Conflicts of interest.



OIG will provide oversight of contracts and contractor functions and performance, including —

  • Active contracts at the Centers for Medicare & Medicaid Services;
  • Administrative costs, contractor executive salaries, and employee benefits and pensions;
  • Benefit integrity activity;
  • Overpayments; and
  • Information systems security programs.


Other Medicare Program Issues

OIG will review —

  • Centers for Medicare & Medicaid Services oversight of hospitals’ security controls for networked equipment;
  • Enhanced screening procedures; and
  • Risk assessment of the pioneer accountable care organization model.


Medicare Parts C and D

  • Medicare Advantage encounter and risk adjustment data;
  • Part D prescription drug plan
    • Risk-sharing payments
    • Sponsor compliance
    • Billing and payment issues, including retail pharmacies, HIV drugs, and coverage-gap discounts.



In 2015, OIG will focus on Medicaid —

  • Prescription drugs, including state and manufacturer compliance with Medicaid requirements and state collection and reporting of rebates;
  • Billing, payment and reimbursement, including state claims for Herceptin, dental services for children, and family planning services;
  • Quality and safety of home health services, community-based care and other services, including adult day health care services, mental health day treatment, HCBS waivers, screening of home health agency workers, access to pediatric dental care, and utilization of preventive screening services for children;
  • Equipment, supplies and other services, including transportation;
  • State management of Medicaid, including use of provider taxes;
  • Information system controls and security; and
  • Medicaid managed care.

The final part of this three-part series will cover OIG’s fiscal year 2015 plans involving legal and investigative activities, and public health and human services reviews.

In the meantime, if you have questions regarding the new plan and your practice, please contact one of our Health Care attorneys.
Image: HHS/OIG
*This article is very general in nature and does not constitute legal advice. Readers with legal questions should consult with an attorney prior to making any legal decisions.