Our series on the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan updates continues with selected healthcare-focused announcements from June through September 2026. Each update below highlights the project focus, potential impacts, and practical compliance considerations for healthcare organizations across the care continuum.
Medicare Payments for Expanded Laboratory Panels
Announced June 11, 2026
OIG plans to study whether Medicare payments for expanded laboratory panels that detect six or more pathogens met Medicare and applicable Medicare Administrative Contractor (MAC) requirements. The project aims to address concerns that some providers may use higher-cost expanded panels when a targeted panel would address the clinical need.
Potential Impacts
Hospitals, laboratories, and physicians may see greater scrutiny of medical necessity, laboratory panel selection, supporting documentation, and reimbursement for multiplex testing.
Compliance Considerations
- Compare ordering criteria with payor and MAC coverage rules.
- Look at diagnosis support and utilization trends.
- Sample high-cost or frequently ordered expanded panels to see whether the record explains why broader laboratory panels were reasonable and necessary.
Medicare Home Health Agency (HHA) Provider Enrollment Trends
Announced June 24, 2026
In response to concerns about the expansion of HHA provider enrollments, OIG announced a project examining trends, patterns, and comparisons that may help identify vulnerabilities in the enrollment process.
Potential Impacts
HHAs and enrollment stakeholders may see greater attention on ownership, enrollment changes, screening, and indicators of potentially elevated program integrity risk.
Compliance Considerations
- Compare enrollment records with ownership disclosures, practice locations, and change-of-information filings for accuracy and required submission dates.
- Organizations may also use enrollment data in routine exclusion, credentialing, and fraud risk monitoring.
Analysis of Antipsychotic Drug Use in Nursing Homes
Announced June 29, 2026
OIG announced a nationwide study of antipsychotic drug use in nursing homes, with a focus on their use to treat residents with dementia. The project extends federal scrutiny of medication use and resident care in long-term care settings.
Potential Impacts
Nursing facilities, prescribers, pharmacies, and health plans may face increased scrutiny of prescribing patterns, clinical justification, informed consent, and quality reporting.
Compliance Considerations
- Compare antipsychotic prescribing and monitoring protocols with current requirements.
- Look for records supporting the diagnosis and patient-specific clinical rationale.
- Consider the use of nonpharmacologic interventions.
- Identify outliers by prescriber, facility, diagnosis, and duration of therapy.
Audit of HHS Governance of AI
Announced July 2, 2026
OIG will consider whether HHS has governance in place, in accordance with federal requirements and guidelines, for the development and use of AI tools for functions such as automation and fraud detection. The audit will evaluate whether the department has a governance framework that includes principles related to transparency, fairness, accountability, cybersecurity, and privacy.
Potential Impacts
The project may shape expectations for healthcare organizations and contractors that use AI in fraud detection, surveillance, administrative automation, and other regulated functions.
Compliance Considerations
- Maintain an inventory of AI systems and accountable owners.
- Document risk classification, system quality procedures, human oversight, privacy and cybersecurity controls, vendor governance, ongoing monitoring, change management, and issue escalation.
- Keep evidence showing how AI-supported decisions are explained, compared with defined criteria, and considered by an accountable person.
Medicare Hospice Payments for Nursing Home Care
Announced July 15, 2026
OIG will quantify Medicare routine home care payments for hospice beneficiaries in nursing homes, estimate potential savings from payment changes that address personal care already required of nursing homes, and study hospices with a high proportion of nursing home beneficiaries.
Potential Impacts
Hospices and nursing home facilities may face payment policy changes and greater scrutiny of service allocation, care coordination, billing, and arrangements involving residents receiving hospice care.
Compliance Considerations
- Clearly distinguish hospice services from nursing home facility obligations.
- Maintain coordinated plans of care and service records.
- Compare contracts and billing with each party’s responsibilities for possible overlap.
- Monitor unusually high nursing home concentration or utilization patterns.
Medicaid Managed Care Prior Authorization Denials & Appeals
Announced July 15, 2026
OIG will examine Medicaid managed care organization (MCO) prior authorization processes to identify potential variation in denials across organizations and patterns among types of services and enrollees.
Potential Impacts
Medicaid MCOs may see closer attention to denial accuracy, required decision time frames, notices, appeal handling, access to medically necessary care, and oversight of delegated utilization management functions.
Compliance Considerations
- Study denial and overturn rates by service, provider, population, and delegate.
- Compare selected decisions with coverage criteria and supporting documentation.
- Compare notices and processing dates against applicable requirements.
- Monitor access and disparity indicators.
- Use appeal outcomes to identify needed changes to criteria, training, or workflows.
Costs of Hospital-Acquired Conditions (HACs) From Ventilator-Associated Events (VAEs)
Announced August 15, 2026
In an effort to support previous recommendations that CMS include VAEs in its list of tracked HACs for Medicare payment purposes, OIG will examine the prevalence of these events among hospitalized Medicare patients and their costs to the program.
Potential Impacts
Hospitals may see greater attention on infection prevention, event surveillance, quality reporting, documentation, and the financial consequences of preventable complications.
Compliance Considerations
- Compare infection prevention and clinical surveillance practices with applicable requirements.
- Compare coding and event capture against source records.
- Look at a sample of ventilated-patient cases and trend outcomes and costs.
- Document corrective actions for recurring control or care process gaps.
Premium Tax Credits for Qualified Health Plan (QHP) & Medicaid Enrollees
Announced August 17, 2026
OIG announced a project examining whether advance premium tax credits (APTCs) were paid to individuals who enrolled in QHPs under the Affordable Care Act while they were enrolled in Medicaid, and therefore ineligible for APTCs.
Potential Impacts
State Medicaid agencies, marketplaces, QHPs, and eligibility vendors may face greater scrutiny of eligibility data exchanges, enrollment reconciliation, termination timing, and prevention or recovery of overlapping federal subsidies.
Compliance Considerations
- Strengthen controls around required eligibility update time frames and cross-program matching.
- Compare enrollment records to identify overlapping coverage periods.
- Retain documentation supporting eligibility decisions and notices.
- Monitor interface exceptions.
- Coordinate corrective action and repayment processes when duplicate coverage or subsidies are identified.
Medicare Advantage Prior Authorization for Part B Drugs
Announced September 15, 2026
OIG will review the use of prior authorization and step therapy for Part B drugs by Medicare Advantage Organizations (MAOs). The project will consider selected case documentation with a focus on alignment with program requirements and clinical guidelines, administrative delays, and patient outcomes.
Potential Impacts
MAOs, delegated utilization entities, prescribers, and provider organizations may see added attention to Part B drug criteria, step therapy protocols, decision records, and effects on access to care.
Compliance Considerations
- Compare prior authorization and step therapy criteria with Medicare requirements and clinical guidelines.
- Look at selected case files for the stated basis of each decision, processing dates, exception handling, notices, and appeal outcomes.
- Track recurring delays or access barriers by drug, diagnosis, provider, and delegate, and use the results to inform criteria, training, and oversight activities.
Medicare Part D GLP-1 Dispensation
Announced September 15, 2026
OIG announced a study of possible overdispensing of glucagon-like peptide-1 (GLP-1) drugs in Medicare Part D. The project will compare GLP-1 use and spending between vertically integrated and non-vertically integrated entities and consider whether ownership structures and dispensing arrangements may contribute to drug waste or higher Part D spending.
Potential Impacts
Part D sponsors, pharmacy benefit managers (PBMs), affiliated pharmacies, prescribers, and compliance teams may see added attention to dispensing quantities, refill timing, utilization patterns, plan-pharmacy financial arrangements, and controls addressing waste.
Compliance Considerations
- Compare days’ supply, refill timing, reversals, discontinuations, and unused-medication indicators for GLP-1 prescriptions.
- Segment utilization and spending by pharmacy affiliation and dispensing channel, document the basis for quantity and refill decisions, and look at ownership and payment arrangements for patterns that may warrant follow-up.
How Forvis Mazars Can Help With Healthcare Compliance
Our healthcare compliance professionals help providers, health plans, and other stakeholders respond to changing regulatory and compliance expectations. We will continue to track OIG Work Plan activity and share quarterly updates on issues that may matter to healthcare organizations. Contact us if you would like to discuss how a project may affect your organization.