OIG Work Plans: Key Compliance Updates for Healthcare Providers
The Office of Inspector General (OIG) at the U.S. Department of Health & Human Services continues to offer detailed guidance on compliance issues crucial for the healthcare sector. To combat fraud, enhance quality and safety, and promote innovation, the OIG provides regular updates via its Work Plan. These updates inform healthcare organizations about ongoing audits and investigations, guiding their compliance initiatives.
For the first quarter of 2026, the OIG's Work Plan outlines several important areas of focus. A key area involves the Centers for Medicare & Medicaid Services (CMS) and its Medicare Advantage (MA) payment adjustments. These payments rely on diagnoses submitted under hierarchical condition categories (HCCs). In 2024, CMS adopted a revised HCC risk adjustment model (V28), expected to save $7.6 billion by reducing payable diagnosis categories. The OIG will evaluate whether these savings were realized.
The 21st Century Cures Act mandates that Medicaid service providers, including fee-for-service (FFS) and managed care organizations (MCOs), must enroll with state Medicaid agencies. The Act restricts federal payments to unenrolled providers. The OIG will review state compliance with this mandate to ensure unenrolled providers do not receive federal funds.
The Indian Health Service's (IHS) Catastrophic Health Emergency Fund (CHEF) reimburses high-cost care from non-IHS providers when services are unavailable within IHS facilities. The OIG plans to examine the management of CHEF from fiscal years 2021 to 2025, reviewing eligibility criteria and reimbursement processes.
To tackle potential fraud, the OIG will investigate whether pharmacies identified as problematic by CMS or Medicare Part D sponsors continue receiving payments, despite existing fraud prevention tools. This review aims to pinpoint lapses in current measures and suggest improvements for detecting and mitigating pharmacy-related fraud within Part D.
Additionally, the OIG conducts an annual review of Medicare Part D formularies to ensure they comply with federal requirements and adequately cover medications for dual-eligible enrollees. This review checks if plan sponsors adhere to regulatory standards while meeting beneficiaries' needs.
Medicare Advantage organizations (MAOs) providing over-the-counter (OTC) supplemental benefits must report these accurately per federal regulations. The OIG intends to audit these organizations to verify their compliance concerning these benefits. Healthcare providers and plans can benefit from staying informed about regulatory changes and compliance requirements. Our team continues to track OIG Work Plan developments to assist organizations across the healthcare spectrum. For more information on OIG compliance guidance, additional resources are available.