Look into My Crystal Ball: Who Is Going to Be Audited by the Government in 2017?

Happy New Year, readers!!! A whole new year means a whole new investigation plan for the government…

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) publishes what is called a “Work Plan” every year, usually around November of each year. 2017 was no different. These Work Plans offer rare insight into the upcoming plans of Medicare investigations, which is important to all health care providers who accept Medicare and Medicaid.

For those of you who do not know, OIG is an agency of the federal government that is charged with protecting the integrity of HHS, basically, investigating Medicare and Medicaid fraud, waste, and abuse.

So let me look into my crystal ball and let you know which health care professionals may be audited by the federal government…


The 2017 Work Plan contains a multitude of new and revised topics related to durable medical equipment (DME), hospitals, nursing homes, hospice, laboratories.

For providers who accept Medicare Parts A and B, the following are areas of interest for 2017:

  • Hyperbaric oxygen therapy services: provider reimbursement
  • Inpatient psychiatric facilities: outlier payments
  • Skilled nursing facilities: reimbursements
  • Inpatient rehabilitation hospital patients not suited for intensive therapy
  • Skilled nursing facilities: adverse event planning
  • Skilled nursing facilities: unreported incidents of abuse and neglect
  • Hospice: Medicare compliance
  • DME at nursing facilities
  • Hospice home care: frequency of on-site nurse visits to assess quality of care and services
  • Clinical Diagnostic Laboratories: Medicare payments
  • Chronic pain management: Medicare payments
  • Ambulance services: Compliance with Medicare

For providers who accept Medicare Parts C and D, the following are areas of interest for 2017:

  • Medicare Part C payments for individuals after the date of death
  • Denied care in Medicare Advantage
  • Compounded topical drugs: questionable billing
  • Rebates related to drugs dispensed by 340B pharmacies

For providers who accept Medicaid, the following are areas of interest for 2017:

  • States’ MCO Medicaid drug claims
  • Personal Care Services: compliance with Medicaid
  • Medicaid managed care organizations (MCO): compliance with hold harmless requirement
  • Hospice: compliance with Medicaid
  • Medicaid overpayment reporting and collections: all providers
  • Medicaid-only provider types: states’ risk assignments
  • Accountable care

Caveat: The above-referenced areas of interest represent the published list. Do not think that if your service type is not included on the list that you are safe from government audits. If we have learned nothing else over the past years, we do know that the government can audit anyone anytime.

If you are audited, contact an attorney as soon as you receive notice of the audit. Because regardless the outcome of an audit – you have appeal rights!!! And remember, government auditors are more wrong than right (in my experience).

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on January 6, 2017, in Administrative Remedies, Adult Care Homes, Appeal Rights, Assisted Living Facilities, Behavioral health, Credible Allegations of Fraud, Denials of Claims, Doctors, Federal Government, Federal Law, Fraud, Health Care Providers and Services, Home Health Care Agencies, Home Health Services, Hospice, Hospitals, Knicole Emanuel, Laboratory Services, Legal Remedies for Medicaid Providers, Long Term Care Facilities, Managed Care, Medicaid, Medicaid Advocate, Medicaid Appeals, Medicaid Attorney, Medicaid Audits, Medicaid Providers, Medicaid Recoupment, Medicaid Reimbursements, Medicare, Medicare and Medicaid Provider Audits, Medicare Appeal Process, Medicare Audits, Medicare RAC, North Carolina, Nursing Homes, Performance audit, Pharmacy, Physicians, Post-Payment Reviews, Prescription Drugs, Program Integrity, Provider Appeals of Adverse Decisions for Medicare and Medicaid, RAC Audits, Regulatory Audits, Self-Audits, Skilled Nursing Visits and tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 2 Comments.

  1. Kathleen L Grumblatt

    There is usually a great similarity of areas to be audited across all states. So, if Dave hasn’t seen the KY list, it will likely be similar.

    Sent from my iPhone Kathleen L Grumblatt, LCSW, DCSW


  2. I have learned to use a Bic – ‘Cristal’ – Medium – Black Pen for clinical notes. My experience is that If I don’t, then during an audit, I will have to do a payback for any session notes written in blue or with an ink roller mechanism. But then, another auditor said that I had to use a Bic – ‘Soft Feel’ Retractable so now I am totally confused on what to do! I guess audits are based on the auditor’s whims and subjective eye as well as whether or not they had a cup of coffee before the audit.

Leave a Reply

%d bloggers like this: