January 2026 OIG Work Plan: Six New Enforcement Signals Compliance Teams Can’t Ignore

The HHS OIG Work Plan is starting off 2026 with a bang by announcing six new work plan items. 

HCC Risk Adjustment Models

Medicare Advantage (MA) compliance remains a high priority for the OIG. MA payments are risk-adjusted based on the health status of each enrolled patient. It is required for MA organizations to submit risk-adjustment data to CMS so CMS can determine each enrollee’s health status.  

CMS will then map certain diagnosis codes to hierarchical condition categories (HCCs), which CMS then uses to increase its payments to the MA organizations. In 2024, CMS began paying MA organizations according to a new model, known as version 28 (V28). The older version was the 2020 model (V24). The new model significantly decreased the number of diagnosis codes that map to an HCC and increased the number of HCCs that CMS uses to increase payments. CMS anticipated that the transition to the V28 model would save over $7.6 billion in payments for 2024 alone.  

The OIG plans to analyze the diagnosis codes that MA organizations submitted to CMS for 2024 to determine whether CMS was able to achieve the savings it had hoped for. 

HHS Terminated Contracts Audit

HHS is one of the largest contracting agencies in the Federal Government. In fiscal year 2024, HHS obligated more than $36.8 billion for 36,042 contracts. Since January 2025, HHS has terminated (full or partial), descoped, or not renewed more than 5,700 contracts.   

The Federal Acquisition Regulation (FAR) has policies and procedures relating to the full or partial termination of contracts for the convenience of the government. When the federal government wants to terminate a contract, they are required to send a written termination notice to the contractor and make a determination to release, or de-obligate, excess funds.  

The OIG plans to determine whether HHS terminated contracts in accordance with federal requirements and applicable contract specifications. 

Autism Spectrum Disorder and NIH

The prevalence of autism spectrum disorder is rising. The National Institutes of Health (NIH) Autism Data Science Initiative (ADSI) is a research effort that will use large-scale data resources to explore contributors to the causes and prevalence of autism spectrum disorder.  

The NIH issued 13 Other Transaction (OT) awards totaling approximately $50 million over a 24- to 36-month period to support the ADSI during fiscal year 2025. 

The OIG’s objective will be to determine whether NIH issued ADSI OT awards in accordance with applicable Federal requirements. 

Audit of Medicaid Unenrolled Providers

The 21st Century Cures Act (the Act) has provisions designed to strengthen Medicaid provider enrollment. The Act required that all providers that serve Medicaid beneficiaries enroll with their State Medicaid agency effective January 1, 2017, for Medicaid FFS and January 1, 2018, for Medicaid managed care organizations (MCOs).  

Additionally, the Act required that no Federal financial participation be paid for managed care expenditures when States have not complied with the requirement to enroll MCO network providers. States also have to return the Federal share of overpayments associated with unenrolled fee-for-service (FFS) providers to CMS.  

The OIG wants to determine whether the State agencies complied with these Federal requirements and prohibited payments associated with providers that were not enrolled in their Medicaid FFS and managed care programs. 

IHS’s Health Emergency Fund

The Indian Health Service’s (IHS’s) Catastrophic Health Emergency Fund (CHEF) was established to meet the extraordinary medical costs associated with the treatment of victims of disasters or catastrophic illness for individuals under IHS’s responsibility. CHEF is used to reimburse Tribal health programs for medical services purchased from non-IHS providers when existing IHS or Tribal facilities cannot provide the care needed or when supplemental funds are needed for comprehensive care. CHEF appropriations are capped annually and must be used as the payor of last resort.  

OIG’s objectives are to:  

1. provide an overview of how IHS administers CHEF 

2. identify any significant changes to the CHEF program during fiscal years 2021–2025 

3. describe the process for reimbursing medical costs of eligible individuals 

Medicare Part D Fraud

Bad-actor pharmacy fraud has long been a concern for the OIG. Fraud puts the Part D program and millions of taxpayer dollars at risk every year. For the other parts of Medicare, CMS has traditionally tried to safeguard Medicare funds with tools such as revocation, preclusion, and payment suspension. However, these traditional tools useful for other parts of Medicare may not be effective at deterring fraud by pharmacies that bill Part D plan sponsors.  

OIG’s review in this area is designed to determine the extent to which pharmacies that have been identified as bad actors by CMS or Part D plan sponsors continue to bill and receive payment for drugs under Part D. The review will seek to describe and identify opportunities for CMS and Part D plan sponsors to improve their ability to detect and reduce potential fraud by pharmacies in the Part D program. 

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