OIG Releases FY 2016 Work Plan And Highlights Exclusion Enforcement

On November 2, 2015, the Department of Health and Human Services Office of Inspector General released their fiscal year (FY) 2016 Work Plan. The Work Plan is released at the beginning of each fiscal year to set forth new and existing projects planned for the coming year. The projects highlighted in the Work Plan are conducted by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General and includes scheduled projects under the Centers for Medicare & Medicaid Services.

The Work Plan also highlights achievements accomplished during (FY) 2015. Here are some noteworthy accomplishments by the numbers.

  • $3 billion estimated savings based on HHS audit and investigative receivables and non-HHS investigative receivables.
  • $20.6 billion savings estimated on the basis of prior-period legislative, regulatory or administrative actions as a result of OIG’s recommendations; a significant increase over last year’s $15.7 billion savings.
  • 4,112 individuals and entities excluded from participation in federal health care programs; a slight increase from last FY.
  • 925 criminal actions taken against parties that participated in crimes against HHS.
  • 682 civil actions related to false claims and unjust-enrichment lawsuits, civil monetary penalties settlements and administrative recoveries as the result of self-disclosures; an increase over last year’s FY civil actions.

Year after year these above figures continue to increase. The growth in savings, the rising number of individuals and businesses being excluded, the increasing number of criminal and civil action all point to a more proactive and engaged OIG.  These enforcement numbers also evidence the importance the OIG places on ensuring the welfare of Medicare and Medicaid beneficiaries.

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The OIG carries out several enforcement actions, including imposing program exclusions and civil monetary penalties and assessments on individuals and entities providing services and items through federal healthcare programs. One enforcement action in particular is the exclusion of individuals and entities from participating in federal healthcare programs. Individuals and entities may be excluded as a result of “program-related convictions, patient abuse or neglect convictions, licensing board disciplinary actions, or other actions that pose a risk to beneficiaries or programs.” The federal healthcare exclusion program is outlined under the Social Security Act, § 1128, § 1156.

In FY 2014 the OIG excluded 4,017 individuals and entities. In FY 2015 that number slightly increased to 4,112. Even though the number of exclusions added remained relatively the same, the OIG’s effort to investigate and exclude over 4,000 new individuals and entities is noteworthy. This has implication on healthcare providers. Healthcare providers are required to screen the growing List of Excluded Individuals and Entities (LEIE). That means that each month in FY 2015 approximately 350 new names were added that could potentially match to a provider’s list of employees and vendors being screened.

Although not specifically highlighted in the FY 2015 Work Plan, the OIG continues to impose civil monetary penalties against providers who engage or hire excluded parties. Therefore, conducting monthly sanction screenings against the LEIE is necessary to ensure excluded parties are not hired or contracted with to provide services or items reimbursed by federal healthcare programs.