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Showing 31 posts in Office of Inspector General of the United States Department of Health and Human Services (OIG).

The Heat Turns Up: The 60-Day Rule Gets a Facelift but Changes Create Complications for Providers

By Lisa English Hinkle, Valerie Michael on June 2, 2025
Posted In Centers for Medicare & Medicaid Services (“CMS”), False Claims Act, Medicaid, Office of Inspector General of the United States Department of Health and Human Services (OIG), Overpayments

With the OIG’s May 30, 2025, announcement that they are seeking $454.4 million in funding to fight healthcare fraud, healthcare providers can expect increased governmental scrutiny despite Trump’s budget cutbacks and staff layoffs.  The OIG justifies its budget request by pointing out that for every $1 invested, there is an expected return of $11 in government recoveries and receivables, which fuels the Trump administration’s fight on fraud, waste, and abuse in health care. What this means for health care providers is intensified scrutiny and likely use of AI as a tool to evaluate big data to identify potential false claims, fraud, outliers, etc. Considering the OIG’s 90-page new General Compliance Guidance, healthcare providers’ self-policing strategies and internal audits are more important than ever as the heat turns up on alleged fraud and false claims. More >

Tags: CMS, False Claims Act, Medicaid, Medicare, Office of the Inspector General (OIG)

OIG, in a Departure, Approves Hospital Provision of Nurse Practitioner Services

By Lisa English Hinkle, Christopher J. Shaughnessy on January 20, 2023
Posted In Department of Health and Human Services (HHS), Health Care Law, Hospitals, Nurse practitioners (NP), Office of Inspector General of the United States Department of Health and Human Services (OIG)

Traditionally, the Office of the Inspector General for the U.S. Department of Health and Human Services (“OIG”) would take a hard stance on any arrangements that might involve some form of remuneration from a hospital to a referring physician, but the winds of change may be blowing. In Advisory Opinion 22-20, published in December of 2022, the OIG has given a green light, albeit in a limited context, to an arrangement in which a hospital may have its employee nurse practitioners perform some services traditionally performed by the patients’ primary care physicians. This is a small step in the direction of a more flexible OIG stance on the federal Anti-Kickback Statute (“AKS”), but it doesn’t completely sidestep risks. More >

Tags: Department of Health & Human Services (“HHS”), health care industry, Health Care Law, Healthcare Organizations, Healthcare Provider, Healthcare Providers, hospitals, nurse practitioners, Office of the Inspector General (OIG)

OIG and CMS Audits Present New Round of Compliance Concerns for Healthcare Providers

By Lisa English Hinkle on February 23, 2022
Posted In Audit, Centers for Medicare & Medicaid Services (“CMS”), COVID-19, Office of Inspector General of the United States Department of Health and Human Services (OIG)

Since the beginning of the Public Health Emergency, Centers for Medicare and Medicaid Services (“CMS”) and the Centers for Disease Control and Prevention (“CDC”) data reflect over 44 million COVID-19 cases, 3 million COVID-19 related hospitalizations, and 720,000 COVID-19 deaths. COVID-19 has placed enormous stress on our healthcare system. Federal and state responses to COVID-19 have woven a complex and complicated safety net by easing regulatory requirements through waivers and funneling billions of dollars to providers among many other actions.  Just as the pandemic may finally be easing, federal focus on use of COVID-19 resources promises to increase healthcare providers’ stress.  More >

Tags: Audit, Centers for Medicare & Medicaid Services, CMS, COVID-19, Healthcare Compliance Issues, Medicaid, Medicare, regulatory compliance

Up, Up and Away: Penalties and CMPs to be Adjusted for Inflation

By Lisa English Hinkle on November 20, 2015
Posted In False Claims Act, Office of Inspector General of the United States Department of Health and Human Services (OIG), Uncategorized

As part of the recent bipartisan budget deal, the Federal Civil Penalties Inflation Adjustment Improvements Act of 2015 (the “Improvements Act”) requires that all federal agencies make inflation-based adjustments to all civil monetary penalties (CMPs) within their jurisdictions beginning no later than August 1, 2016. In the health care context, the legislation means that the penalties available to the government under the Civil Monetary Penalties Law (CMPL), as well as the False Claims Act (FCA), must be adjusted for inflation and increased. More >

Tidbits and Takeaways from OIG’s 2016 Work Plan

By Lisa English Hinkle on November 17, 2015
Posted In "Two Midnights Rule", 340B Program, Centers for Medicare & Medicaid Services (“CMS”), Hospice, Office of Inspector General of the United States Department of Health and Human Services (OIG), Skilled Nursing Facilities (“SNFs”)

The Office of Inspector General for Health and Human Services (“OIG”) recently issued its 2016 Work Plan, which sets the agenda for its auditing and investigation in the year ahead. The broad mandate of the OIG is to eliminate fraud, waste and abuse. With the requested FY 2016 budget of $417 million, the OIG will continue its fraud-fighting efforts and heighten it focus on reducing waste in HHS programs. Waste includes not only fraud, but also unnecessary services, inefficient delivery of care or service, poor quality of care or services, inflated prices, excess administrative costs, or mismanagement of grant or contract funds. With a 2015 track record of $3 billion in recoveries; 4,112 provider exclusions from participation in federal health care programs; 925 criminal actions and 682 civil and administrative enforcement actions and a return on investment of $8 for every $1 spent, the OIG is a force to be avoided. The yearly work plan provides a list of priorities for the office, and in turn gives providers insight into areas of concern in practice. The following areas are on OIG’s radar for the coming year: More >

OIG Alert Shows Increased Concern over Data Blocking

By Christopher J. Shaughnessy on October 27, 2015
Posted In Anti-Kickback Statute, EHR Systems, Electronic Health Records (“EHR"), Office of Inspector General of the United States Department of Health and Human Services (OIG)

In a report to Congress last April, the Office of the National Coordinator for Health Technology addressed the growing issue of data blocking. Data blocking occurs when some person or entity knowingly and unreasonably interferes with the exchange or use of electronic health information (“EHI”), and this happens due to business incentives that cause those persons or entities to want to control and limit availability to that information. For instance, if one ACO has the capability to send EHI of a patient safely and securely to another ACO treating that patient through a certified health IT system, but instead faxes that patient’s information, it has engaged in data blocking. It has made it more difficult, inefficient and expensive for the rival ACO to treat that patient. In essence, data blocking prevents the exact purpose of the HITECH Act and provisions of the Affordable Care Act which were designed to increase interoperability of electronic health information systems and facilitate the exchange of information. These broad concerns over data blocking found footing in a recent Office of Inspector General (“OIG”) Alert stressing that data blocking can run afoul of the Federal Anti-Kickback Statute. More >

OIG Targets Questionable Billing Practices for Ambulance Services

By Anne-Tyler Morgan on October 20, 2015
Posted In False Claims Act, Fraud, Health Care Fraud, Medicare, Office of Inspector General of the United States Department of Health and Human Services (OIG)

The Office of the Inspector General (“OIG”) pulled no punches in a recent report on Medicare Part B billing for ambulance transports. The September release presented a case for increased scrutiny, pointing out that Medicare has historically been vulnerable to fraud where ambulance transports are concerned. For instance, a 2006 OIG report determined that 25% of billed ambulance transports did not meet Medicare requirements in Calendar Year 2002. That year, Medicare paid almost $3 billion for ambulance services, and improper payments accounted for an estimated $402 million of that total. As 2012 saw Medicare pay $5.8 billion for ambulance services, the OIG took an even closer look at this category of claims. More >

Structuring Healthcare Provider Agreements for Compliance

By Christopher J. Shaughnessy on June 25, 2015
Posted In Anti-Kickback Statute, Health Care Fraud, Office of Inspector General of the United States Department of Health and Human Services (OIG), Stark Laws

On June 23rd, the Healthcare Law Blog discussed the Fraud Alert recently issued by the Office of Inspector General of the United States Department of Health and Human Services regarding physician compensation arrangements which telegraphed the Office of Inspector General’s intention to increase scrutiny of financial arrangements between physicians and providers to whom physicians make referrals. In today’s post, we examine the steps physicians and other healthcare providers should take to ensure that any financial relationships are in compliance with federal statutes and regulations. More >

OIG Fraud Alert Targets Physician Compensation Arrangements

By Christopher J. Shaughnessy on June 23, 2015
Posted In Anti-Kickback Statute, Fraud, Health Care Fraud, Office of Inspector General of the United States Department of Health and Human Services (OIG), Stark Laws

It bears repeating so much that even the Office of Inspector General of the Department of Health and Human Services just issued a Fraud Alert on it – physician compensation arrangements are fraught with potential violations of the Anti-Kickback Statute (“AKS”) as well as the Stark Statute and regulations. The AKS is a large enough trap that it catches even the most above-board agreements in its net, and physicians should be wary of the implications. Likewise, the Stark Statute and regulations are broad and are strict liability laws: if you do not meet a Stark exception, the referral and the resulting claim are tainted and the money received based upon the tainted claim must be repaid to the government. More >

Kentucky to Establish Hospital-to-Home Transition Care

June 9, 2015
Posted In Kentucky’s Department for Medicaid Services, Office of Inspector General of the United States Department of Health and Human Services (OIG)

One of the last-minute laws passed by Kentucky’s General Assembly and signed by Governor Beshear was a statute that authorizes Medicaid reimbursement for “Hospital-to-Home Transition Care,” which becomes effective on June 24, 2015. More >

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