How Does OIG Target Provider Types for Audits and Who Needs to Worry?
Interestingly, how OIG and who OIG targets for audits is much more transparent than one would think. OIG tells you in advance (if you know where to look).
Prior to June 2017, the Office of Inspector General’s (OIG) OIG updated its public-facing Work Plan to reflect those adjustments once or twice each year. In order to enhance transparency around OIG’s continuous work planning efforts, effective June 15, 2017, OIG began updating its Work Plan website monthly.
Why is this important? I will even take it a step further…why is this information crucial for health care providers, such as you?
These monthly reports provide you with notice as to whether the type of provider you are will be on the radar for Medicare and Medicaid audits. And the notice provided is substantial. For example, in October 2017, OIG announced that it will investigate and audit specialty drug coverage and reimbursement in Medicaid – watch out pharmacies!!! But the notice also states that these audits of pharmacies for speciality drug coverage will not begin until 2019. So, pharmacies, you have over a year to ensure compliance with your records. Now don’t get me wrong… you should constantly self audit and ensure regulatory compliance. Notwithstanding, pharmacies are given a significant warning that – come 2019 – your speciality drug coverage programs better be spic and span.
Another provider type that will be on the radar – bariatric surgeons. Medicare Parts A and B cover certain bariatric procedures if the beneficiary has (1) a body mass index of 35 or higher, (2) at least one comorbidity related to obesity, and (3) been previously unsuccessful with medical treatment for obesity. Treatments for obesity alone are not covered. Bariatric surgeons, however, get a bit less lead time. Audits for bariatric surgeons are scheduled to start in 2018. Considering that 2018 is little more than a month away, this information is less helpful. The OIG Work Plans do not specific enough to name a month in which the audits will begin…just sometime in 2018.
Where do you find such information? On the OIG Work Plan website. Click here. Once you are on the website, you will see the title at the top, “Work Plan.” Directly under the title are the “clickable” subjects: Recently Added | Active Work Plan Items | Work Plan Archive. Pick one and read.
You will see that CMS is not the only agency that OIG audits. It also audits the Food and Drug Administration and the Office of the Secretary, for example. But we are concerned with the audits of CMS.
Other targeted providers types coming up:
- Security of Certified Electronic Health Record Technology Under Meaningful Use
- States’ Collection of Rebates on Physician-Administered Drugs
- States’ Collection of Rebates for Drugs Dispensed to Medicaid MCO Enrollees
- Adult Day Health Care Services
- Oversight of States’ Medicaid Information Systems Security Controls
- States’ MCO Medicaid Drug Claims
- Incorrect Medical Assistance Days Claimed by Hospitals
- Selected Inpatient and Outpatient Billing Requirements
And the list goes on and on…
Do not think that if your health care provider type is not listed on the OIG website that you are safe from audits. As we all know, OIG is not the only entity that conducts regulatory audits. The States and its contracted vendors also audit, as well as the RACs, MICs, MACs, CERTs…
Never forget that whatever entity audits you, YOU HAVE APPEAL RIGHTS!
Posted on November 8, 2017, in Administrative code, Administrative Remedies, Alleged Overpayment, Appealing Adverse Decisions, Audits, CMS, DHHS, Doctors, Due process, Federal Government, Federal Law, Health Care Providers and Services, HHS, Hospitals, Knicole Emanuel, Legal Analysis, Managed Care, Medicaid, Medicaid Attorney, Medicaid Audits, Medicaid Providers, Medicaid Recoupment, Medicaid Services, Medicare, Medicare Administrative Contractor, Medicare Attorney, Medicare Audits, Medicare RAC, North Carolina, Office of Inspector General, Pharmacy, Physicians, RAC, RAC Audits, Regulatory Audits, Self-Audits, States, ZPICs and tagged Bariatric Surgery Audits, Centers for Medicare and Medicaid Services, CMS, Gordon & Rees, GORDON & REES LLP, Knicole Emanuel, MCO Medicaid drug claim audits, Meaningful use, Medicaid, Medicaid Attorney; Medicaid Lawyer; Medicare Attorney Medicare Lawyer, Medicaid Audits, Medicare, Medicare and Medicaid Audits, Medicare Audits, Office of Inspector General, OIG, OIG Work Plan, Pharmacy audits, RAC Audit, RACs, Regulatory Audits, Speciality drug audits, Telehealth, Telehealth Audits. Bookmark the permalink. Leave a comment.