10/07/2025
🔍 Top OIG Audit Targets for 2026 — and How Healthcare Organizations Can Stay One Step Ahead
(with a dash of humor — because compliance deserves a smile too)
Let’s face it — the OIG doesn’t exactly send out “You Pass!” postcards. But if you want to avoid surprise audit headaches in 2026, here are the areas they’re most likely to spotlight. Cue ominous audit music.
1️⃣ Managed Care & Risk Adjustment (Medicare Advantage / Medicaid Managed Care)
Because nothing says “fun” like an audit of diagnosis codes and risk scores.
Why they’ll dig here:
OIG plans audits of diagnosis codes submitted for risk adjustment, especially those lacking supporting documentation or face-to-face encounters.
They’re also watching for enrollment manipulation — enrolling people without consent or “cherry-picking” healthier members.
Examples / red flags:
• MA plan submits high-risk codes without solid documentation
• Agents earning bonuses for “selective” enrollments
• Claims still processed after member disenrollment
Tip: Audit your risk adjustment data, confirm coding accuracy, and document every encounter.
📎 Source: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp
2️⃣ Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Because yes — even your DME can end up on the OIG’s naughty list.
Why they’ll dig here:
OIG continues to focus on fraud, waste, and abuse within DMEPOS, especially around new billing schemes, accessories, and delivery verification.
Examples / red flags:
• Supplying scooters or oxygen concentrators with flimsy documentation
• Billing for “upgrades” not ordered by the physician
• Phantom suppliers or duplicate claims
Tip: Verify LCD requirements, confirm medical necessity, and keep supply-chain records tight.
📎 Source: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp
3️⃣ Home Health & Skilled Services
Because “home sweet home” doesn’t mean “audit free.”
Why they’ll dig here:
Recent OIG audits found unsupported billing and missing documentation in home health agencies. Expect scrutiny over skilled-need qualifications, plans of care, and remote patient monitoring claims.
Examples / red flags:
• Billing skilled therapy with no clear necessity
• Plans of care missing signatures or mismatched visits
• Remote monitoring data never reviewed or integrated
Tip: Perform internal audits, review plans of care regularly, and ensure real-time documentation.
📎 Source: https://oig.hhs.gov/reports/all/2025/medicare-home-health-agency-provider-compliance-audit-hrs-home-health/
4️⃣ Grants, Contracts & Public Health Programs
Because the OIG isn’t just about claims — it’s about every federal dollar.
Why they’ll dig here:
OIG’s 2025–2030 Strategic Plan highlights grant and contract oversight to prevent waste and mismanagement. Public health grants, pandemic relief funds, and subcontractor compliance will all be examined closely.
Examples / red flags:
• Deliverables that don’t match performance reports
• Charging the same expense to multiple grants
• Weak oversight of subcontractors or consultants
Tip: Segment grant accounting, tighten controls, and audit subrecipients early.
📎 Source: https://oig.hhs.gov/about-oig/strategic-plan/
5️⃣ Nursing Facilities & Long-Term Care
Because the OIG has a soft spot for residents — and a hard line on compliance failures.
Why they’ll dig here:
Expect continued focus on psychotropic drug use, staffing levels, and resident safety.
OIG recently released Industry Segment–Specific Compliance Program Guidance (ICPG) for skilled nursing facilities — and it’s a must-read.
Examples / red flags:
• Antipsychotic drugs without clear diagnosis or consent
• Inadequate staffing ratios or missing shift coverage
• Failure to report safety or quality metrics
Tip: Adopt ICPG guidance, review prescribing trends, and strengthen your QAPI program.
📎 Source: https://oig.hhs.gov/reports-and-publications/workplan/
📎 Budget report:https://www.hhs.gov/sites/default/files/fy-2026-oig-cj.pdf
🎯 Why 2026 Will Be Tougher (and a little less funny)
• The OIG’s FY 2026 budget request emphasizes stronger Medicare & Medicaid oversight.
• Expect more use of data analytics and AI to detect anomalies.
• Priority areas: Managed Care, Nursing Homes, and Federal Grants.
📎 Source:https://www.hhs.gov/sites/default/files/fy-2026-oig-cj.pdf
⚠️ Compliance Caveats & Fine Print
This post is for educational purposes only and not legal or regulatory advice.
Always consult your compliance, audit, or legal counsel before making operational changes.
The OIG’s Work Plan is updated frequently — check the latest version here:
👉 https://oig.hhs.gov/reports-and-publications/workplan/
💬 Compliance humor of the day:
“If you think nobody’s watching, remember — the OIG has better data analytics than Santa Claus.” 🎅📊
