OIG to analyze skin substitute payments, incident-to billing, HRAs

Revenue integrity professionals should be aware of recent additions to the Office of Inspector General’s (OIG) Work Plan, as they often indicate areas of noncompliance.

In previous reviews, the OIG has found that Medicare Advantage (MA) organizations may have leveraged health risk assessments (HRA) to maximize risk-adjusted payments. In turn, the OIG plans to take a closer look at MA organizations’ compliance with federal guidelines when doing the following:

• Submitting diagnoses reported on HRAs for use in CMS’ risk-adjustment program
• Taking any needed steps to ensure continuity of care and integration of services for enrollees who had received HRAs

Improving the transparency of incident-to services is critical to program integrity efforts, according to the OIG. As a result, the office plans to review Part B payments for services performed incident-to physicians' services.

The OIG also plans to analyze Part B skin substitute claims to identify noncompliant payments. This decision stems from a substantial increase in Part B skin substitute payments between 2020 and 2023.

All three audit reports are expected to be published in 2026. Review the OIG’s Work Plan items and ensure your organization is in compliance and prepared to respond to an audit.

Editor’s note: Find more NAHRI coverage of OIG audits and reports here.