Here's a heads-up that all healthcare providers, including mental health, substance use disorder treatment providers, and other behavioral health organizations need to note:

The Office of Inspector General (OIG) of the Department of Health and Human Services wants a $67.2 million budget increase for FY 2025 for greater oversight and enforcement actions.

The significant increase would enable the OIG “to remain an agile organization that pivots quickly to address emerging risks,” according to Inspector General Christi A. Grimm.

Grimm explained the reasons behind her request for the increase in an FY 2025 Justification of Estimates report prepared for Congress and published in March.

The report outlines a total budget request of $499.7 million to oversee U.S. Department of Health and Human Services programs. The total budget amount is $67.2 million, greater than the FY 2023 budget.

In a written message included in the Justification of Estimates, Grimm said the increase would “support urgent and unmet needs with strategic investments in PIG’s oversight and enforcement activities.”

What providers can expect

This budget request tells us clearly that the OIG wants greater scrutiny and increased numbers of fraud and overpayment investigations in FY 2025. It echoes the overall emphasis on compliance we’re seeing from the OIG in the post-pandemic era.    

 Specifically, the FY 2025 budget includes a joint HHS and Department of Justice (DOJ) legislative proposal for the Health Care Fraud and Abuse Control ) program to combat serious healthcare fraud and abuse in Medicare, Medicaid, and the Children’s Health Insurance Program.

“The funding levels for the mandatory HCFAC streams have not been reset in more than a decade,” Grimm said in her message. She added that the increase would “ensure that taxpayer dollars are not misspent, patients receive quality care, and fraudsters are held accountable.”

Intensifying OIG focus on compliance

The call for additional funds to make greater oversight and enforcement possible is the latest signal that the OIG is intensifying its focus on compliance. It’s all part of a strategic plan the OIG has outlined for 2021-2025 to meet three objectives:

  • Fight fraud, waste, and abuse
  • Promote quality, safety, and value in HHS programs and for HHS beneficiaries
  • Advanced excellence and innovation

The strategic plan also sets priorities for safeguarding the Medicare trust funds by combating cybersecurity threats and protecting beneficiaries from prescription drug abuse, including opioids.

We’ve seen several new initiatives and new regulations inspired by and aligned with the goals set out under the strategic plan. The OIG is keeping a close watch on all the major changes in the healthcare market and ramping up overall compliance expectations accordingly.

The OIG General Compliance Program Guidance

In November of 2023, the OIG released the most comprehensive new compliance guidance ever issued, with key updates for the recommended compliance approach for all types of healthcare providers.

Previously, many providers lacked any definitive compliance guidance. Instead, they relied on self-knit compliance programs based on previous advisories and rulings for other types of providers and general best practices. In some cases, guidance for a particular healthcare sector had not been updated for the past 25 years.

The OIG’s General Compliance Program Guidance is known as the GCPG. It references Federal laws, compliance program infrastructure, OIG resources, and other information for understanding all aspects of healthcare compliance. It reiterates the need for organizations to meet seven specific compliance elements and fully involve leadership and the organization’s governing board in compliance monitoring.

How SimiTree can help

The Office of Inspector General (OIG) developed its strategic plan to be dynamic so that it can accommodate a rapidly changing health and human services environment, including emergent threats and vulnerabilities.

Your organization’s compliance program is expected to be equally dynamic. It’s vital to evaluate your organization and compliance program for potential risks, perform regular audits, and update policies and procedures accordingly.

If your healthcare practice or organization has not had a full compliance assessment since the new guidance came out, it needs one now. New policies, processes, and procedures may be required. At a minimum, a round of staff training is probably needed.

SimiTree’s compliance experts work with providers to determine where they may be at risk of HIPAA privacy and security violations, including recent HIPAA changes, and identify any weaknesses in required oversight from leadership for compliance programs.

We help organizations put into place all OIG-recommended elements of compliance infrastructure, identify areas of risk in billing practices, and offer pre-bill audits to see where an organization may be incurring risk or shortchanging itself.

SimiTree’s former auditors and surveyors are well-equipped to help organizations with all their compliance needs, from full compliance assessments to ADRs, audits and appeals, survey readiness, and plans of correction. We also assist with the execution of OIG Corporate Integrity Agreements.

Read the full Justification of Estimates report here:
FY 2025 OIG Budget.pdf (hhs.gov)

Read the OIG Strategic Plan 2020-2025 here:
Strategic Plan 2020–2025

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Have a compliance question?

SimiTree’s healthcare experts can help! Our team is made up of former auditors and surveyors from across healthcare settings who help behavioral health organizations achieve accreditation from AOs, understand regulatory and compliance demands, and meet quality goals. We have the know-how and the experience to help your organization mitigate risk. Contact us today with all your compliance needs.

J’non Griffin serves as Senior Vice President/Principal for the Compliance as well as Coding divisions at SimiTree. Her healthcare career spans three decades of clinical and leadership experience, and she has a track record of helping many provider types implement effective compliance programs. She is a certified ACHC and CHAP consultant and holds additional certifications in diagnosis coding and other healthcare specialties. As an AHIMA ambassador, she was instrumental in the implementation of ICD-10.