This review of the OIG FY2016 Work Plan will provide the various section(s) that were identified by the OIG that may affect the Pathology/Laboratory specialty. It does not include a comprehensive review of all components of the Work Plan. This document is for “informational use only” and it is not intended to provide legal advice or counseling on the various topic(s). If the reader has concerns or questions they should consult with their legal counsel for advice.

The OIG released its Fiscal Year 2016 (FY2016) Work Plan on Oct. 30, 2015. The work plan is published annually, with a mid-year update, when applicable and provides the OIG’s current ongoing audit and enforcement initiatives as well as identifying any new priorities for the upcoming year. The work plan is a very useful tool in indentifying compliance risk areas and focus for ongoing efforts relating to compliance program activities, audits and policy development.

The OIG identified several new areas of focus for the FY2016 plan as well as revised items from previously year’s plans. The OIG rolled over last year’s item for independent laboratory billing activities into this year’s plan to analyze potential overpayments. They also discussed the Centers for Medicare and Medicaid’s (CMS) new Clinical Lab Fee Schedule project that will base the fee schedule on private payer rates. OIG indicates they will conduct an annual analysis and monitor Medicare expenditures and the new payment system for laboratory tests. OIG added a new review for CMS’s early management of the implementation of the ICD-10 and may review the effectiveness of that implementation as well as how the new system may affect claim submissions and denials.

The OIG Work Plan outlines the current focus areas and states the primary objectives of each project. The word “New” in the project title indicates the project did not appear in the previous Work Plan. At the end of each project description, the OIG provides the internal identification code for the review (if a number has been assigned), the year in which they expect one or more reports to be issued as a result of the review, and whether the work was in progress at the start of the fiscal year or is planned as a new start.

The OIG states that “[i]n fiscal year (FY) 2016 and beyond, OIG will expand its focus on delivery system reform and the effectiveness of alternate payment models, coordinated care programs, and value-based purchasing.  Areas under consideration for new work include, for example, a holistic examination of HHS’ efforts to reduce opioid abuse, adherence to safety standards in Administration for Children and Families’ Unaccompanied Children Program, and evaluation of CMS’s Fraud Prevention System. OIG will periodically update its online Work Plan, available at http://www.oig.hhs.gov.”¹

A companion document, FY 16 Justifications of Estimates for Appropriations Committees, provides what the OIG oversight is for Medicare/Medicaid. They state “OIG’s oversight work in FY 2016 will target wasteful spending, including improper payments, unreasonable payment methodologies, and unsafe or low quality health care. Oversight of specific programmatic areas includes Medicaid expansion—including beneficiary enrollment, managed care, and the sufficiency of data used for oversight; prescription drug fraud and abuse; home- and community-based services (HCBS) fraud; promoting industry compliance; contracting and contractor oversight; Medicare Advantage payment accuracy; home health agency compliance and payments; and new payment and delivery models in Medicare and Medicaid.”² The full document (PDF, 892 KB) provides the OIG accomplishments, return on investment and other budgetary request for FY16 as well as past return on investments and enforcements actions (i.e. sanctions, civil and criminal actions).

The items selected in this document contain only those that may pertain to the Pathology/Laboratory Specialty (directly or indirectly). Providers are encouraged to read the full work plan to better assess their own individual business activities against the work plan. To view a complete version of the OIG 2016 Work Plan, Click here.

¹Office of Inspector General Work Plan FY2016 – Introductory Message from the Office of Inspector General – A note about this edition.
²OIG FY2016 Justification of Estimates for Appropriations Committees, Page 27.

Author - Male

About the author

Rick Oliver, CPCO, CPC, MT(ASCP) is Compliance Director in Laboratory and Pathology of McKesson Business Performance Services.