OIG Explained: How It Impacts Your Healthcare Facility

The Office of Inspector General (OIG) has improved the efficiency, integrity, and credibility of healthcare provision in the United States of America since 1976. This office has spearheaded the fight against abuse, misuse, wastage, and fraud in the medical field. It creates internal compliance controls (statutes and regulations) and monitors adherence to those controls.

OIG monitors more than 100 HHS (Department of Health and Human Services) programs, including Medicaid and Medicare. The organization runs a compliance program that ensures all healthcare facilities in the US operate in an ethical, honest, and accountable manner. If you’re a healthcare practitioner, you can access a compliance checklist on the OIG website to confirm if your practice is compliant.

What OIG does, has a huge impact on all US-based healthcare facilities, from nursing homes to hospitals to medical equipment suppliers. Among other impacts, OIG:

1. Healthcare compliance and reputation management

OIG compliance safeguards the integrity of healthcare services in your facility. It serves as a testament to your facility’s dedication to ethical healthcare practices and commitment to high-quality care for patients. OIG compliance is what tells patients that your facility is reputable and the employees can be trusted, which then promotes the integrity of your facility’s healthcare services.

With this in mind, your facility must have comprehensive policies and procedures tailored toward achieving OIG healthcare compliance. These policies should touch on:

• Proper documentation and recordkeeping of all claims made within a fiscal year.
• Regular financial audits.
• Employee training programs that meet prevailing industry standards.
• Best billing practices.
• Regular system audits to identify and correct potential non-compliance areas.
• Auditing vendors to ensure they’re not engaged in suspicious activities.

2. Fraud detection

OIG protects the general public from healthcare fraud by ensuring that healthcare providers are ethical in their service delivery. If your facility engages in fraud, OIG is authorized by the federal government to disqualify the facility’s Medicare and Medicaid reimbursements. But fraud detection shouldn’t worry you much because OIG provides comprehensive compliance program guidance documents to healthcare providers. These documents have all the regulations and statutes related to fraud detection and control in the American healthcare system. With the program guidance documents, you can develop internal controls for monitoring cases of potential fraud, which keeps you OIG compliant.

3. OIG Exclusions List

The OIG exclusions list is a database of healthcare providers (both individuals and entities) that have been prohibited by OIG from providing healthcare services within the USA. These individuals or entities cannot be reimbursed from Medicaid, Medicare, or any other healthcare program that’s funded by the federal government. Their prohibition could be due to either a history of abusing patients or being involved in fraudulent activities. OIG draws its authority to create this list from section 1128 of the Social Security Act. The exclusion list is updated every month.

The OIG exclusions list is meant for:

• Protecting your facility’s integrity and that of federal healthcare programs by weeding out unethical practitioners from the medical profession.
• Deterring potential quacks and fraudsters from messing up the healthcare industry. the vast majority of physicians are honest, dedicated, and ethical
• Maintaining public trust in the healthcare system by ensuring that patients are attended to only by qualified individuals.
• Providing transparency to patients, so they can tell can easily confirm your credibility as a healthcare provider.
• Maintaining ethical practices and protecting patient safety.
• Safeguarding your practice from legal penalties, loss of reputation, or unwanted financial repercussions.
• Ensuring that fraudsters don’t defraud the government, which consequently keeps federal healthcare programs running.
• Helping you streamline your hiring process in order to get credible employees. You can identify and dismiss applicants with a fraud history early on by performing an OIG check.

An OIG check is the process of checking whether a healthcare provider is listed in the OIG exclusion list. For more information about how OIG works, please go through these OIG check FAQs.

4. The OIG work plan

There are many state and federal laws and regulations that protect the general public from potential abuse, waste, and fraud by healthcare providers. These laws change just as fast as the healthcare industry evolves. You can easily fail to comply with the laws not because you chose to but because you’re unable to keep up with the changes. That can lead to costly and tedious audits and sanctions. That’s where the OIG work plan comes in handy.

The IOG work plan gives you a checklist of the laws and regulations you need to comply with during a given fiscal year. It also sets goals and objectives that healthcare providers need to achieve in a given time and how they are supposed to go about it. Most importantly, the Work Plan tells you what kinds of claims OIG is going to target when they come to audit your billing process.

Note: The OIG creates the Work Plan and publishes it every fiscal year.

5. Evaluation of proper physician billing

OIG audits healthcare businesses so as to avoid overspending, theft, and wastage in the healthcare industry, particularly with regard to Medicare and Medicaid. Theft and wastage of funds in government-funded healthcare initiatives hurt the beneficiaries the most because they end up not receiving the quality of services they need and deserve. That’s on top of hurting the taxpayer’s and the federal government’s fiscal health

OIG audits target and audit specific sections of your billing that are known to be the most vulnerable to fraud. Remember you have the Work Plan that helps you conduct a thorough internal audit of your billing efforts. The OIG ensures that you have all the information you need to fix your own unintended errors in your billing process before your practice is audited. One potential error that you need to be wary of is over-collection from the government. Your targeted internal audits, with the help of the Work Plan, will help you find and correct such a costly unintentional error.

There you have it! OIG works for honest healthcare providers to ensure that their practice isn’t encroached on by dishonest fraudsters.  It provides you with many tools to assist you in running a compliant and reputable medical facility.

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