This blog will provide some key points on how you can incorporate the current Office of Inspector General (OIG) items and future items into your organization’s auditing and monitoring functions.  Paying attention to what the OIG for Health and Human Services (HHS) plans to audit and monitor during the upcoming year should be a one of the key drivers in developing your own annual audit plan.

As a reminder, auditing and monitoring is one of seven key elements of an effective compliance program. Auditing and monitoring program functions can help an organization identify risks to business, assists with preventing real or potential risks from escalating and shows a good faith effort that you are truly looking at your own processes and controls.

Although the OIG no longer publishes out an annual work plan, you can still prepare your organization’s compliance work plan as was done in the past. However, this year, as the pandemic has affected all of our operations and even our compliance work plan effectiveness you may approach it a bit differently. One approach is to go to the OIG work plan and look at the items that have been added since the public health emergency began. You can then sort through them for the applicable items related to your organization’s services. Although the plan is specific to what the OIG plans to audit in respect to HHS programs, it provides a plan of the audits that organizations may experience as well. The OIG items covers Medicare, Medicaid, FDA, Substance Abuse/Mental Health, Public Health, Indian Health Services and Other.

After reviewing the OIG items, you may consider some questions related to your 2021 compliance work plan including:

  • Has the public health emergency (PHE) resulted in items to add to your plan?
  • Due to the PHE, will you be narrowing the focus of you plan? Or expanding your plan?
  • Were there items you deferred during 2020?

Some of the most notable recent and active OIG work plan items include:

Telehealth Services

  • In October 2020, CMS announced the plan to begin auditing Medicare Telehealth Services. CMS has implemented a number of waivers and flexibilities that allowed Medicare  beneficiaries to access telehealth services. Medicare Part B and C data will be reviewed for program integrity risks associated with telehealth services during the pandemic. OIG will analyze provider billing patterns. Although there isn’t a lot of detail, you should continue to watch for updates and review once the initial audit is published.
  • OIG will also be reviewing Medicaid Telehealth for oversight of state agencies and waivers that occurred during the PHE.
  • OIG will also focus on selected States use of telehealth in behavioral health services. It will analyze how these States and managed care organizations (MCOs) use telehealth to provide behavioral healthcare. It will also review selected States’ monitoring and oversight of MCOs’ behavioral health services provided via telehealth.

Laboratory Billing for Potential Fraud and Abuse with COVID-19 Add-on Testing

In June 2020, OIG added an item related to laboratory add-on tests to confirm or rule out a diagnosis other than COVID-19 as well as the ordering provider. These add-on tests in conjunction with COVID-19 testing – respiratory pathogen panel (RPP) tests, allergy tests or genetics tests will be reviewed for medical necessary and appropriateness.

Two-Midnight Rule for Inpatient Admissions

In November 2020, the OIG announced a revised plan to begin auditing short stay claims in 2021 related to the implementation of the Two-Midnight Rule in Fiscal Year 2014. Under this rule, it is generally considered inappropriate to receive payment for stays not expected to span at least two midnights.

Other key items to look at for 2021 include waiving or reducing co-payments under telehealth policy, infection control items related to guidance in some areas, Medicaid provider enrollment, COVID inpatient discharges, cybersecurity review of HHS, review of CARES Act, Provider Relief Funds, emergency preparedness and other long standing OIG audit areas.

No matter the time an organization reviews the OIG Work Plan, this resource is important in creating an annual audit plan and educating leadership on ongoing OIG activities.

Written by Aurae Beidler, MHA, RHIA, CHC, CHPS