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Ignorance is Not Bliss: Get to Know the OIG FY 2016 Work Plan

The Department of Health and Human Services Office of Inspector General (HHS-OIG) recently released its FY 2016 Work Plan, in which it identified key areas of focus for the upcoming year. Consistent with its mandate to detect fraud, waste, and abuse, and to hold accountable those who do not meet program requirements or who violate Federal health care laws, the OIG’s Work Plan outlines several enforcement initiatives. As a result of the its enforcement initiatives in FY 2015, the OIG excluded over 4,000 individuals and entities from Federal health care program participation and expects to recover over $3 billion in Federal health care program payments. The 2016 Work Plan runs the gamut of the healthcare industry and offers providers a valuable tool for staying ahead of OIG’s enforcement and recovery initiatives.

What Providers Should Know

OIG’s FY 2016 Work Plan makes clear that OIG remains committed to ensuring that Federal health care program funds are appropriately used and are recouped where necessary. The OIG conducts audits, evaluations, and investigations to uncover instances of health care fraud and abuse and can impose civil monetary penalties (CMP) where appropriate. Given that CMPs under both the FCA and the Civil Monetary Penalties Law are set to increase by virtue of the newly enacted Bipartisan Budget Act of 2015, it is more important than ever for providers to ensure that they are in compliance with the multitudinous rules and regulations governing the provision of health care services. Health care providers should use the Work Plan as a tool to guide their compliance efforts both now and in the future.

What’s New in FY 2016

For the upcoming fiscal year, the OIG added many new or revised areas of focus. The corresponding FY 2016 audits, evaluations, and investigations will inevitably affect a wide range of providers, though to varying degrees. The following is a sampling of the OIG’s new or revised concerns and plans, identified by provider or service type:

  • Hospitals

  • Nursing homes

  • Therapy billing

  • Hospice

  • Physicians

  • Accountable Care Organizations (ACOs)

  • Pharmacies

  • Medical Equipment & Supplies

  • Prescription Drugs

  • All Providers

What’s Still a Priority

Many areas of focus in years past remain a priority for OIG in FY 2016. Overall, OIG continues to focus on identifying improper and/or fraudulent claims for services that were not medically necessary. In FY 2016, the OIG plans specifically to continue its enforcement efforts on the following:

  • Hospitals

  • Home health

  • DMEPOS Suppliers

  • End Stage Renal Disease (ESRD) Facilities

  • Laboratories

  • Nursing homes

  • Medicaid Program Integrity at the State Level

Payment suspensions following a credible allegation of fraud are required by state Medicaid programs unless the program affirmatively determines that a payment suspension could have an adverse effect on an investigation or on Medicaid beneficiaries. Not all states have robustly implemented this rule, but are likely to do so following publication of the 2016 Work Plan. Providers should educate AR staff on the possibility of payment suspensions so they can respond quickly and effectively.

To view or download the full PDF, click here.

© Polsinelli PC, Polsinelli LLP in CaliforniaNational Law Review, Volume V, Number 321


About this Author

Brian D. Bewley, Polsinelli PC, Federal investigations Lawyer, False Claims Act litigation Attorney, Washington D.C.

Brian Bewley provides comprehensive representation to a broad range of health care organizations in fraud and abuse and compliance matters. He brings value that clients appreciate with his perspective and reasoned advice — which was formed through his years of experience operating as a senior health care fraud attorney with both the Office of Inspector General for the Department of Health and Human Services (OIG-HHS) and the Department of Justice.

Brian routinely represents organizations under federal and state investigations based on alleged...

Brian F. McEvoy, Polsinelli PC, Atlanta, white collar criminal defense lawyer, health care fraud matters attorney

Brian McEvoy is an accomplished litigator with a well-earned reputation for working tirelessly to achieve the best outcomes for clients and for thinking creatively and strategically to resolve difficult problems with efficiency and professionalism. Brian is a former federal prosecutor with a practice focus on white collar criminal defense and a special emphasis in health care fraud matters. During his service as a federal prosecutor, he received special commendation from the Department of Health and Human Services by receiving the Inspector General's Integrity Award for his work prosecuting Health Care Fraud matters. In 2008, he was named as the District's Health Care Fraud Coordinator and started the District's first Health Care Fraud Task Force.

Jennifer L. Evans, Polsinelli PC, Denver, healthcare fraud matters lawyer, medicare reimbursements attorney

Jennifer Evans brings legal, legislative and operational experience to health care matters. Her legal practice is focused on fraud and abuse, Medicare and Medicaid reimbursement issues, and regulatory compliance. Jennifer has experience working with clients that include multistate service providers to chronic patients, multistate pharmacies, Durable Medical Equipment companies, hospitals, physician practice managers, laboratories, health care management franchisors, and a specialty services extension of a physician practice.

Jennifer also served...

Dayna C. LaPlante, Polsinelli PC, Chicago, Complex Healthcare Matters Attorney, Administrative Compliance Lawyer,

Dayna LaPlante works with clients who benefit from her diligence, enthusiasm and strong grasp of the complex health care legal sector. She represents a range of health care providers, including hospitals, pharmacies, and long term care providers. Dayna focuses her general practice on helping clients maintain compliance with state and federal law, and represents clients in civil and administrative litigation should disputes arise. She also serves as regulatory counsel for health care transactions, helping clients remain in regulatory compliance post-closing. 

Kevin M. Coffey, Polsinelli PC, Chicago, Planning Advocacy Lawyer, Compliance matters Attorney

Kevin Coffey blends advocacy skills and a proactive planning approach in providing comprehensive health care legal representation to a broad range of organizations in fraud and abuse and compliance matters. He works closely with clients to proficiently respond to investigations based on alleged violations of various civil, criminal, and administrative laws, including the False Claims Act and OIG’s Civil Monetary Penalties. Kevin is well-versed in federal and state health care regulatory schemes and laws.