OIG Work Plan updated to include trend analysis to determine fraud and abuse in COVID-19 add on testing and review of expanded telehealth services

The OIG Work Plan sets out the various projects, audits and evaluations that the OIG will focus its efforts on each year. It is updated monthly and when finalized, the reports are publicized with recommendations. This alert will highlight two of the recent updates. Further updates to the Work Plan can be found here.  

First, in June 2020 the OIG added “Trend Analysis of Medicare Laboratory Billing for Potential Fraud and Abuse With COVID-19 Add-on Testing” to its Work Plan. The OIG has concerns about the potential for fraud and abuse related to add-on testing to confirm or rule out a COVID-19 diagnosis. In particular, the OIG is concerned about potentially fraudulent billing of associated respiratory pathogen panel (RPP) tests, allergy tests, or genetic tests. The OIG states that the relaxation of rules surrounding COVID-19 testing may lead unscrupulous actors to fraudulently bill or fraudulently increase test frequency. The Work Plan analysis will focus on finding patterns of billing by labs that might indicate fraud and abuse.  It is worth noting that the OIG, along with most healthcare related agencies, are very sophisticated at using data analytics and artificial intelligence (AI) to identify these patterns.  Proper and detailed documentation is critically important during this public health emergency (PHE) period in order to provide appropriate support for all billed claims.

Second, just this month, the OIG is adding a review related to the CMS changes that allow for expanded use of the telehealth services during. These changes are currently temporary and set to end with the conclusion of the PHE, but CMS is considering making these changes permanent. There will be two reviews associated with this consideration:

• The “first review will examine the extent to which telehealth services are being used by Medicare beneficiaries, how the use of these services compares to the use of the same services delivered face-to-face, and the different types of providers and beneficiaries using telehealth services.”
• The “second review will identify program integrity risks with Medicare telehealth services to ensure their appropriate use and reimbursement during the COVID-19 pandemic.”

We believe that the OIG will use data analytics and AI to identify risks to the program integrity for these reviews as well.

For further information on either of these two OIG Work Plan updates, or any others, please contact the attorneys below.