July 2025 OIG Work Plan: 6 Compliance Areas to Watch

The OIG added many items to its work plan in July 2025. Below we have summarized a few of these items most likely to affect health care provider organizations. 

Medicare Hospital Compliance Audits

For many years, the OIG performed hospital compliance reviews, see: https://oig.hhs.gov/reports-and-publications/series/hospital-compliance.asp  

The last review listed was issued in November of 2020. With this newly added OIG Work Plan item, it appears the OIG may begin to perform more of these types of audits.   

The OIG intends for this review to be a part of a series of compliance reviews focusing on hospitals with claims that may be at risk for Medicare overpayments. OIG will review Medicare payments to acute care hospitals to determine hospitals' compliance with selected billing requirements and recommend recovery of overpayments and hospital-specific compliance remediation measures. 

Misleading Marketing

Medicare Advantage organizations market the plans they sell to seniors. OIG mentions concerns about aggressive and deceptive marketing practices by some of these organizations. The focus of the concerns is on agents and brokers who target and mislead seniors. Sometimes these agents enroll beneficiaries in plans without their knowledge or directing them to plans that increase their out-of-pocket costs.  

With this background in mind, OIG plans to examine Medicare Advantage marketing practices and the harm they cause to individuals. It will focus on the complaints individuals reported to CMS from 2020 to 2024 about Medicare Advantage marketing practices.  

They will also look at the actions taken by agents and brokers that led to the complaints and the incentive structures that encourage brokers to change individuals' enrollments. 

Organ Procurement Audit

In the United States, there is one program that operates the nation's organ procurement, allocation, and transplantation system. The program also aims to increase access to donor organs for patients with end-stage organ failure. The name of this program is the Organ Procurement and Transplantation Network (OPTN), and it is managed by the Health Resources and Services Administration (HRSA). 

Recently, there have been deficiencies throughout OPTN. As a result, HRSA announced the first multivendor OPTN contract awards to improve patient safety, modernize IT, increase transparency and public engagement in policy development, strengthen patient-centered communications, and improve financial management.  

The OIG plans to audit these processes to determine whether HRSA awarded the OPTN contracts in accordance with Federal requirements. 

Medicaid Managed Care and Behavioral Health Services

Achieving milestones in childhood is an important aspect of health, including mental health. Children should reach both developmental and emotional milestones. They also need to learn healthy social and coping skills to help solve problems they encounter. The Medicaid program has a mandatory early and periodic screening, diagnostic, and treatment (EPSDT) benefit that requires children under the age or 21 who are enrolled in Medicaid, to receive all medically necessary services, including behavioral health services, which include services for mental and substance use disorders. Medicaid programs are run by individual States. Many States’ Medicaid plans offer behavioral health services coverage.  

The OIG plans to examine and discover the extent to which children enrolled in Medicaid received EPSDT medical screenings and, if diagnosed with a behavioral health condition, whether behavioral health treatment services were provided. Their review will also determine whether States and managed care organizations have met Federal and State requirements for providing EPSDT behavioral health services. 

Long-Term Care Services

According to the OIG, $72.5 billion was spent in one year on managed long-term service and supports (MLTSS) programs. There are approximately two million Medicaid patients who are supposed to receive these services every year. 

A prior OIG audit in one state (https://oig.hhs.gov/reports/all/2020/new-jersey-did-not-ensure-that-its-managed-care-organizations-adequately-assessed-and-covered-medicaid-beneficiaries-needs-for-long-term-services-and-supports/) showed that in 68 of 100 monthly capitation payments, managed care organizations did not comply with the requirements to adequately assess and cover the associated beneficiaries' needs for long-term services and supports. 

OIG plans to study and determine the extent to which States made capitation payments to MLTSS plans for enrollees who were not provided any long-term care services, as well as the dollar value of such capitation payments, at a national level. 

Hospitals’ Billing for Drugs

The OIG has expressed concern that sometimes hospitals might be billing for drugs that are different than the drugs patients actually received. For hospitals to submit accurate claims for drugs in the outpatient setting, they need to use standardized codes such as Healthcare Common Procedure Coding System (HCPCS) codes. Drugs also have assigned National Drug Codes (NDCs), which are unique numbers used to identify drugs in the United States. These are assigned to HCPCS codes. 

Specifically, OIG is concerned hospitals may be billing for administered drugs using an HCPCS code different from the one assigned to the NDC reported on the claim. They plan to identify ways in which Medicare is potentially vulnerable to improper payments when hospitals bill for drugs with HCPCS codes that do not match those assigned to the NDCs listed on the claims. 

Conclusion

Compliance professionals should review these and any other OIG Work Plan items that might affect their organizations. They should also consider the risk their organizations have in these areas and determine if proactive auditing and monitoring might be appropriate.

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