What the March 2026 OIG Work Plan Updates Reveal About Emerging Compliance Risk

March 2026 was a busy month of announcement for the OIG’s Work Plan. Compliance officers and auditors should review the recent announcements and adjust their compliance work plans and annual audit plans as necessary.

Chronic Care Management (CCM) Services Audit

It’s been a little over 10 years since Medicare began paying for chronic care management (CCM) services. During that time, utilization and total payments by Medicare for these services has steadily increased. The OIG has specifically noted that from calendar year 2019 through calendar year 2024, Medicare Part B payments for CCM services increased substantially.

CCM is care coordination that occurs outside of a regular office visit for patients with two or more chronic conditions that:

1. are expected to last at least 12 months or until the patient dies

2. place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

In a prior audit, the OIG found that Medicare continued to make overpayments for Chronic Care Management services, which they concluded was costing the program and its beneficiaries millions of dollars.

Around twenty months ago, the U.S. Department of Justice announced a $14.9 million settlement with a chronic disease management provider to resolve alleged false claims related to chronic care management services.

For this Work Plan item, OIG intends to review Medicare Part B payments for CCM services that may be at risk of noncompliance with the Medicare requirement for multiple chronic conditions.

Modifier 25

That pesky modifier 25 will just not go away as a compliance and coding risk. Modifier 25 is appended, and bypasses Medicare non-payment edits, when there is a significant, separately identifiable evaluation and management (E/M) service performed on the same day as a minor procedure. When this modifier is appended, the billing provider is affirming the clinical situation and accompanying medical documentation supports its use which will lead to additional reimbursement for the provider. Otherwise, Medicare would not pay for the E/M service since they consider it included in the payment for the minor procedure.

Generally, Medicare reimbursement for an evaluation and management (E/M) service performed on the same day as a minor surgical procedure is included in the payment for the procedure.

The OIG and DOJ have both been involved in audits and enforcement actions for alleged inappropriate use modifier 25. The following are just some examples:

• Vohra Wound Physicians and its Owner Agree to Pay $45M to Settle Fraud Allegations of Overbilling for Wound Care Services https://www.justice.gov/opa/pr/vohra-wound-physicians-and-its-owner-agree-pay-45m-settle-fraud-allegations-overbilling
• Connecticut Physiatrist and Practice Pay $427k to Settle False Claims, Improper Billing Allegations https://www.justice.gov/usao-ct/pr/connecticut-physiatrist-and-practice-pay-427k-settle-false-claims-improper-billing
• Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements https://oig.hhs.gov/documents/audit/10286/A-09-23-03014.pdf
• Podiatrists’ Claims for Evaluation and Management Services Did Not Comply With Medicare Requirements https://oig.hhs.gov/documents/root/11292/A-09-22-03012.pdf
• screening, assessment, and treatment planning
• medication monitoring consistent with State plan requirements

According to the OIG, analysis of Medicare paid claims data for E/M services provided by Part B providers during calendar years 2023 through 2025 identified payments for E/M services performed on the same day as a minor surgical procedure that were processed and paid without a modifier 25 appended. The OIG plans to determine whether the Medicare Administrative Contractors’ processing and payment of these E/M claims complied with Medicare requirements.

Part C and Over-the-Counter Items

Medicare Advantage (MA) continues to be a high priority for OIG oversight. Recall, the most recently published OIG Compliance Guidance is specifically written for MA compliance. Healthicity has an eBrief and a webinar covering some of these key updates.

MA plans are allowed to offer supplemental benefits, such as over-the-counter (OTC) benefits, to support patient health. These benefits are funded through rebates and must be used on CMS-approved, health-related items. In 2024, CMS required MA organizations to report utilization and cost data for OTC benefits. However, the approaches to deliver this benefit by MA organizations can vary and there is not a great deal of visibility into how funds are spent or whether all enrolled Part C beneficiaries are able to access the benefit.

Given this risk, the OIG plans to audit selected MA organizations to determine whether OTC benefits are being accurately reported to CMS and administered in accordance with Federal requirements.

Children Receiving Psychotropic Medication

In the past, OIG performed oversight work related to treatment planning and medication monitoring for children in foster care who were receiving psychotropic medication.

They found that in five states, one in three children in foster care who were treated with psychotropic medications did not receive treatment planning or medication monitoring as required by States. Additionally, the Administration for Children and Families (ACF) has suggested that States consider practice guidelines from professional organizations, including the American Academy of Child and Adolescent Psychiatry, (AACAP) related to treatment

planning and medication monitoring. The OIG concluded that State requirements for oversight of psychotropic medication did not always incorporate these professional practice guidelines.

The OIG has stated that many years after OIG’s review, high rates of psychotropic medication use among children in foster care remain concerning. Although psychotropic medications can be effective treatments for children in foster care, they should be used as part of a comprehensive treatment plan, and the children who are prescribed them must be closely monitored by providers.

In this Work Plan item, the OIG will use foster care case file documentation and Medicaid claims data to determine whether children received treatment planning and medication monitoring in accordance with applicable requirements. For five selected states, the OIG will assess the extent to which children in foster care who were prescribed psychotropic medication received:

In addition, the OIG announced they will explore—with states and Administration for Children and Families—potential causes for any noncompliance with state plan requirements, and potentially beneficial practices implemented by states with high rates of compliance with state plan requirements.

Medicaid Coverage for Nonqualified Individuals

Medicaid has certain requirements that individuals must meet before they qualify for coverage under this taxpayer funded program. Individuals meet Medicaid eligibility criteria by satisfying certain Federal and State requirements related to income, residency, citizenship, immigration status, and documentation of citizenship.  Federal Medicaid benefits are generally limited to individuals who are citizens or nationals of the United States or qualified individuals, such as lawfully permitted permanent residents, asylees, or refugees.

Many qualified noncitizens are not eligible for full Medicaid benefits until five years from the date they enter the United States with qualified alien status.  Nonqualified individuals and qualified individuals who are subject to but have not yet met the five-year waiting period are restricted from receiving full-scope Federal Medicaid benefits and are eligible only for emergency Medicaid services.  

However, States may elect to provide Medicaid coverage for nonqualified individuals using state-only funds.  The OIG plans to publish a data brief that will describe which types of services were covered as Medicaid emergency medical services for nonqualified individuals in selected states and claimed for Federal reimbursement.

Neurostimulator Implantation Surgeries

Neurostimulator implantation surgeries are regularly performed in an attempt to treat or manage patients with chronic pain. Certain neurostimulator medical devices may be implanted during an inpatient procedure. Medicare covers the initial implantation and replacements or revisions to the device.

Hospitals must meet Federal requirements for neurostimulator implantation surgeries to be covered by Medicare. Prior OIG audit work determined that Medicare made improper payments to hospitals for outpatient claims for neurostimulator implantation surgeries. In this audit report, OIG concluded that Medicare overpaid $636 million for neurostimulator implantation surgeries.

Currently, CMS requires prior authorization for outpatient neurostimulator implantation surgeries, but not for inpatient neurostimulator implantation surgeries. Prior authorization helps CMS ensure that applicable requirements are met before the services are provided. CMS’s lack of prior authorization for inpatient neurostimulator implantation surgeries may leave this area vulnerable to potential improper payments.

Given this vulnerability, OIG plans to determine whether CMS made Medicare payments to hospitals for inpatient neurostimulator implantation surgeries in accordance with Federal requirements.

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