The HHS Office of Inspector General (OIG) recently issued several new work plan items outlining audits it intends to perform and initiative it intends to undertake. OIG investigations and initiatives can concern activities by federal healthcare programs like Medicare and Medicaid, their contractors, and participating providers. However, it is often providers who experience the downstream impacts of OIG initiatives. Healthcare providers should be aware of OIG’s enforcement priorities.
First, OIG intends to review Medicaid nonemergency medical transportation services. OIG noted that such services can pose a significant risk of fraud, waste, and abuse in Medicaid and that past OIG work has identified significant vulnerabilities in State and Federal efforts to reduce fraud, waste, and abuse involving nonemergency medical transportation in Medicaid. It appears that OIG intends to conduct targeted reviews of certain nonemergency medical transportation providers. Such providers should be prepared for increased levels of scrutiny from OIG and their local Medicaid programs.
Second, OIG intends to produce a white paper regarding fraud, waste, and abuse related to durable medical equipment (DME) in Medicare. DME has long been an area of concern for the Medicare program and federal law enforcement and OIG noted that that recent cases demonstrate that fraudsters continue to target DMEPOS billing and have developed new schemes. OIG intends to build on its extensive experience with DME fraud and provide further information about the nature of DMEPOS fraud in Medicare, key program integrity vulnerabilities, and potential actions to reduce fraud, waste, and abuse.
Third, OIG intends to conduct comparisons of Average Sales Prices (ASPs) and average manufacturer prices and market prices for the last three quarters of 2025 and the first quarter of 2026. When Congress established ASP as the basis for Medicare Part B drug reimbursement, it also required OIG to conduct such comparisons and recommend price adjustments to HHS. These comparisons may be particularly relevant in the field of amniotic grafts and skin substitute products, where ASP data is notoriously unreliable and disconnected from available market prices.
Lastly, OIG opened new initiatives directed at member enrollment under Medicaid managed care and Medicare Advantage plans. OIG intends to audit state Medicaid agencies and Medicaid managed care organizations (MCOs) to determine whether the MCOs are properly screening new adult enrollees for mental health services, and whether Medicaid programs are conducting appropriate oversight. OIG also intends to undertake a large-scale analysis of Medicare Advantage enrollment and disenrollment data to identify aberrant patterns that may signal improper actions by Medicare Advantage plans to influence beneficiary enrollment.
For over 40 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to OIG initiatives or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or [email protected]
