In late 2016, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) released its 2017 Work Plan. The plan lists the topics in which OIG sees the greatest potential for fraud under federal health care programs, primarily Medicare and Medicaid. The OIG updates its Work Plan throughout the year as conditions warrant.

In Part I, we discussed OIG investigations and enforcement. In this alert we turn to some of the specific areas of concern listed in the Work Plan, particularly those regarding hospitals, nursing homes, and other health care providers and suppliers. The list below is not exhaustive, but merely serves to highlight some of the areas of concern noted in the work plan.


Hospitals are specifically cited by OIG for a number of targeted oversight efforts in the 2017 Work Plan, including:

  • The use of hyperbaric oxygen therapy (HBO) in wound treatment
  • The use of intensity-modulated radiation therapy (IMRT) in the treatment of malignant tumors
  • A nationwide review of cardiac catheterizations and endomyocardial biopsies
  • Outlier payments for inpatient psychiatric facility stays and short-stay outpatient claims
  • Compliance reviews focused on hospital inpatient and outpatient billing

Nursing Homes and Skilled Nursing Facilities

OIG names the following areas of concern regarding nursing homes and skilled nursing facilities (SNF):

  • Unreported incidents of potential abuse and neglect
  • Overcharges to Medicare for higher levels of therapy (physical, speech, occupational, etc.) than were provided or were reasonable or necessary
  • Compliance reviews focused on the prospective payment system related to a 3-day qualifying inpatient hospital stay
  • SNF facilities with high rates of patient transfers to hospitals for potentially preventable conditions (urinary tract infections, for example), will be reviewed

Hospice, Home Health Services and Other Providers

A number of additional providers are also cited in the Work Plan, including hospice facilities, medical equipment suppliers, durable medical equipment suppliers, and others. Items of concern in these areas include:

  • Hospice medical and billing records will be reviewed to determine compliance with Medicare standards, along with an assessment of quality of care and services
  • Home health care services continue to show high rates of improper payment and unnecessary treatment and will be subject to ongoing review by OIG
  • Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are cited for various concerns including:
    • Inappropriate payments for DMEPOS provided during Non-Part A nursing home stays
    • DMEPOS supplier billing for services that were not medically necessary or were improperly documented
    • An examination of payments between DMEPOS manufacturers and physicians who have ownership or investment interests in the manufacturing entity in instances where Medicaid is paying for all or part of the DMEPOS
  • Suppliers of positive-airway pressure (PAP) equipment and replacement parts auto-shipping of supplies without requested refills or proper documentation
  • Payment for advanced life support emergency transports that were not medically necessary
  • Overpayments for inpatient rehabilitation facility (IRF) services that are not billed in compliance with Medicare documentation and coverage requirements
  • Charges for chiropractic services that were not medically necessary or were improperly documented
  • The submission of claims for “prolonged services” by physicians following the performance of a standard evaluation and management (E/M) service
  • Overpayments for anesthesia services that are non-covered or billed with improper modifiers