OIG’s 2016 Work Plan Expands Focus on Delivery System Reform

Board members overseeing risk management and compliance can now view the chief healthcare regulatory agency’s 2016 Work Plan, a blueprint of projected investigations over the coming year.


The Department of Health and Human Services Office of Inspector General (OIG) issued its work plan in early November and noted that it “will expand its focus on delivery system reform and the effectiveness of alternative payment models, coordinated care programs and value-based purchasing.” (Work Plan Fiscal Year 2016, Office of the Inspector General, Department of Health and Human Services, November 2, 2015)


Some of the key areas of focus in the plan include:


  • Reviewing Medicare payments to acute care hospitals to determine whether certain outpatient claims billed to Part B for services provided during inpatient stays were allowable. OIG said prior work identified this area as at risk for noncompliance with Medicare billing requirements.
  • Reviewing how hospitals’ use of outpatient and inpatient stays changed under Medicare’s Two-Midnight Rule.
  • Comparing Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to clinics for similar procedures, as part of a project to assess the potential impact of claiming provider-based status for such facilities.
  • Reviewing accountable care organizations that participate in the Medicare Shared Savings Program to gauge their performance so far on quality measures and cost savings over the first three years of the program.
  • Determining the extent to which CMS validated hospital inpatient quality reporting data used for the hospital value-based purchasing program and the hospital-acquired condition reduction program.


The Work Plan also has a greater focus on existing “projects” that OIG expects to complete in 2016. These projects focused on cost reporting, medical education payments and outlier payments:


  • Reviewing Medicare outlier payments to hospitals to determine whether CMS performed necessary reconciliations in a timely manner.
  • Analyzing salary data from Medicare cost reports and hospitals to identify salary amounts included in operating costs reported to and reimbursed by Medicare.
  • Reviewing hospitals’ reporting of wage data used to calculate wage indexes for Medicare payments.
  • Determining whether hospitals received duplicate or excessive graduate medical education payments.


In addition to the above, other areas of investigation include ICD-10 implementation, drug reimbursement and Affordable Care Act-related work.


To read the 2016 OIG Work Plan, click here.



(Additional sources: OIG Issues 2016 Work Plan, AHLA Weekly, November 13, 2015 and “What Does OIG’s 2016 Work Plan Mean for Hospitals?” AHLA Practice Groups Email Alert, November 13, 2016)



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