Within the U.S. Department of Health & Human Services (HHS), the Office of Inspector General (OIG) outlines detailed guidance on key compliance areas for the healthcare community and its stakeholders. As part of the OIG strategic plan to address fraud, waste, and abuse; promote quality, safety, and value; and advance excellence and innovation; the office regularly issues Work Plan updates regarding current audits and investigations into healthcare programs. These updates provide transparency and awareness for healthcare organizations and compliance professionals and may serve as indicators for proactive compliance.
This article highlights some of the high-impact OIG Work Plan updates from the first quarter of 2026 and important compliance considerations for healthcare organizations.
CMS-HCC Risk Adjustment Models
Date of Work Plan Update: January 15, 2026
CMS adjusts Medicare Advantage (MA) payments based on enrollee diagnoses submitted by health plans, which are then mapped to hierarchical condition categories (HCCs) used to set payment levels. CMS moved to a new HCC risk adjustment model (V28) in 2024 that reduced payable diagnosis mappings and was expected to save $7.6 billion. OIG will analyze MA coding patterns to understand whether the anticipated cost savings were met.
Potential Impacts
- MA payment reductions based on the new adjustment model’s diagnosis code mapping.
- Changes to coding, documentation, and data processes and methodologies due to HCC adjustments under the new model.
- Increased scrutiny of data by CMS.
Compliance Considerations
- Medicare Advantage Organizations (MAOs): Review and implement changes to systems to accurately capture HCC codes under the updated risk adjustment model.
- Risk Adjustment & Coding Vendors: Review diagnosis capture, coding accuracy, and data submission practices to reflect the updated risk adjustment model.
Medicaid Unenrolled Providers
Date of Work Plan Update: January 15, 2026
The 21st Century Cures Act requires all providers that serve Medicaid beneficiaries, both fee-for-service (FFS) and managed care organizations (MCOs), to be enrolled with their state Medicaid agency. The statute prohibits federal payment for services rendered by unenrolled providers. OIG will assess whether states complied with these requirements and prohibited federal funds paid to unenrolled providers.
Potential Impacts
- Loss of federal funding for Medicaid providers that are out of compliance with enrollment requirements.
- Financial liability for states that may be required to return federal payments.
- Increased monitoring and corrective actions for provider enrollment.
Compliance Considerations
- Medicaid MCOs: Review provider networks to verify enrollment status.
- Medicaid FFS & Network Providers: Review enrollment status to confirm compliance with requirements.
Administration of the IHS Catastrophic Health Emergency Fund
Date of Work Plan Update: January 15, 2026
The Indian Health Service’s (IHS) Catastrophic Health Emergency Fund (CHEF) reimburses Tribal health programs for high‑cost care obtained from non‑IHS providers when required services are unavailable within IHS or Tribal facilities. OIG will review the administration of CHEF, including changes from fiscal years 2021 through 2025, and outline the eligibility and reimbursement process.
Potential Impacts
- Reimbursement delays due to process and policy changes.
- Limited availability of funds for future care outside of IHS.
- Greater scrutiny of reimbursements to confirm CHEF funds are used as a payor of last resort.
Compliance Considerations
- Tribal Health Programs & Tribal Health Organizations: Review policies, procedures, and documentation processes for compliance with CHEF funding requirements.
- Non-IHS Healthcare Providers Treating Eligible Individuals: Review claims processes to improve billing coordination with Tribal programs and providers.
Pharmacy Fraud in Medicare Part D
Date of Work Plan Update: January 15, 2026
To address fraud concerns, OIG will assess whether pharmacies identified as bad actors by CMS or Part D sponsors continue to bill and receive payments under Medicare Part D, despite existing fraud prevention tools. OIG will review potential gaps in current safeguards and identify opportunities for CMS and plan sponsors to better detect and reduce pharmacy‑related fraud in the Part D program.
Potential Impacts
- Expanded oversight programs, reporting requirements, and enforcement actions by CMS.
- Increased monitoring obligations to support anti-fraud efforts.
Compliance Considerations for Medicare Part D Plan Sponsors & Pharmacy Benefit Managers (PBMs)
- Review billing and audit practices for alignment with Part D requirements.
- Review and strengthen monitoring controls to improve detection and response to potential fraud.
- Maintain clear records of investigations and corrective actions related to fraud mitigation efforts.
Dual-Eligible Enrollee Access to Drugs Under Part D
Date of Work Plan Update: February 17, 2026
OIG is required by statute to conduct an annual review of Medicare Part D formularies to assess whether they adequately cover drugs commonly used by dual‑eligible (Medicaid and Medicare) enrollees who receive drug coverage through Part D. Through the annual review, OIG will seek to understand whether plan sponsors are using their formulary discretion in compliance with federal requirements while meeting the needs of the enrollees.
Potential Impacts
- Increased scrutiny of Part D formularies serving dual-eligible enrollees.
- Revisions to existing formularies to support adequate coverage for dual-eligible enrollees.
Compliance Considerations for Medicare Part D Plan Sponsors & PBMs
- Review formulary coverage for dual‑eligible enrollees for compliance with formulary rules under 42 CFR Section 423.120.
- Review policies and procedures for coverage determinations and exceptions for dual‑eligible enrollees.
Utilization & Oversight of Medicare Part C Supplemental Benefits
Date of Work Plan Update: March 16, 2026
MA plans may offer over-the-counter (OTC) supplemental benefits funded by CMS-approved rebates, but benefits must be limited to eligible health-related items and accurately reported. OIG will audit MAOs to confirm compliance with federal requirements for reporting and administration of OTC benefits.
Potential Impacts
- Increased audits and reporting requirements for OTC benefits.
- Corrective and enforcement actions related to OTC benefit administration.
Compliance Considerations for MAOs
- Monitor and validate accuracy of OTC supplemental benefits and utilization.
- Review administration of benefits for compliance with CMS requirements.
Medicare Payments for Chronic Care Management Services
Date of Work Plan Update: March 16, 2026
CMS allows payment through Medicare Part B for chronic care management (CCM) services for patients with multiple serious chronic conditions. OIG will assess whether payments complied with Medicare requirements and the multiple chronic condition criteria.
Potential Impacts
- Increased monitoring of CCM eligibility and billing.
- Expanded reporting requirements to confirm eligibility and compliance.
Compliance Considerations for Health Plans & Providers
- Validate enrollee eligibility for CCM services and monitor claims and billing.
- Review documentation processes to confirm records clearly reflect diagnosis and care plans.
How Forvis Mazars Can Help With Healthcare Compliance
Our healthcare compliance professionals have extensive experience helping providers and health plans navigate regulatory changes and compliance requirements. We will continue to monitor and provide updates on the OIG Work Plan and potential implications for organizations across the continuum of care. If you would like assistance or have questions about how these updates may affect your organization, please reach out to our team.