On January 21, 2026, the Office of Inspector General (“OIG”) for the U.S. Department of Health and Human Services (“HHS”) submitted its Fall 2025 Semiannual Report to Congress, identifying investigative outcomes relating to HHS program administration and operations during the six‑month period from April 1, 2025 through September 30, 2025. Similar to prior semiannual reports, OIG’s findings provide a helpful roadmap for identifying risk areas and enforcement priorities as regulatory scrutiny continues in 2026.
This blog post highlights four areas of particular interest for health care stakeholders and outlines practical regulatory compliance considerations.
Wound Care (Skin Substitutes)
OIG identified Medicare Part B spending on skin substitutes as a significant and growing HHS program integrity concern. Specifically, OIG reported that Part B spending on skin substitutes provided in non‑institutional settings had increased 640% in just two years, exceeding $10 billion annually, with notable disparities between original Medicare Part B and Medicare Advantage (“MA”) utilization.
For health care stakeholders, certain key compliance takeaways include:
- Evaluating whether skin substitute utilization and units billed per patient are clinically appropriate and supported by documentation.
- Assessing site‑of‑service patterns, particularly the use of skin substitutes in home care settings that drive significantly higher per‑patient costs.
- Reviewing product selection practices and rapid shifts to high‑cost skin substitute products for consistency with clinical decision‑making rather than reimbursement incentives.
- Understanding and monitoring potential risks created by Medicare’s payment methodology for skin substitutes, including higher payments for new products, payment delays that can inflate reimbursement, and incentives tied to percentage‑based add‑on payments.
- Identifying and remediating billing patterns that OIG has associated with potential risk, including excessive quantities, use for non‑approved conditions, use without prior conservative treatment, and billing concentrated among atypical provider specialties.
Remote Patient Monitoring
Remote patient monitoring (“RPM”) recently became a priority area for OIG as Medicare payments for RPM reached $536 million in 2024, representing a 31% increase from 2023. Based on OIG’s report, here are some key compliance considerations:
- Monitoring growth in RPM enrollment to ensure billing reflects supportable clinical expansion rather than an onset of new patients.
- Confirming that a prior in‑person or telehealth relationship exists with patients before billing for RPM.
- Ensuring RPM services include ongoing treatment management, with providers frequently reviewing patient data and using it to make clinical care decisions.
- Reviewing whether RPM is being billed for patients who are also receiving RPM services from other providers, which may indicate, according to OIG, duplicative or unnecessary services and thus, billing.
- Verifying that billing reflects no more than one RPM device per patient per month, absent clear justification, to avoid potential duplicative billing or billing for unnecessary devices.
- Using internal auditing and monitoring to identify and assess RPM billing patterns that OIG has flagged as potentially warranting further scrutiny, including high percentages of patients without prior history of RPM use.
Managed Care
Given the scale of enrollment in managed care plans and government expenditures relating to such enrollment, OIG continues to prioritize oversight of MA and Medicaid managed care organizations. OIG’s report highlights audits identifying overpayments tied to potentially inaccurate or otherwise noncompliant risk‑adjustment program diagnosis coding.
Some key compliance takeaways for plans and providers providing and billing for these services include:
- Strengthening controls around diagnosis code submission for MA risk adjustment to ensure codes are supported by medical records and reflect active conditions.
- Identifying high‑risk diagnoses that may warrant heightened review, particularly where unsupported coding may result in inflated risk‑adjusted payments.
- Evaluating the effectiveness of compliance and ethics programs designed to prevent, detect, and address potentially improper payments, including retrospective reviews and corrective action processes.
- Reviewing whether the plan receives and incorporates State or Medicaid Fraud Control Unit training and feedback on referrals of potential fraud, given OIG’s finding that training is associated with higher referral rates.
- Ensuring fraud referral staff have sufficient focus and resources dedicated to Medicaid managed care, rather than being spread across multiple lines of business.
Nursing Homes
As explained in its report, OIG continues to identify systemic quality‑of‑care deficiencies in nursing homes, including understaffing, infection control failures, underreporting of resident falls, and noncompliance with employee background check requirements. OIG’s report highlights enforcement actions, including False Claims Act settlements and exclusions, tied to allegedly substandard care and resident harm.
For health care stakeholders owning, operating, and providing services in nursing homes, certain key compliance considerations include:
- Reviewing whether falls resulting in major injury and hospitalization are fully and accurately reported in required resident assessments.
- Evaluating reporting practices for younger residents, male residents, short‑stay residents, and residents covered by Medicare only, where OIG reported finding higher rates of unreported serious falls.
- Confirming that required background checks are completed before employees begin work, consistent with Federal requirements and industry standards.
- Verifying that required neglect and abuse registry queries are completed before employees begin work, where applicable under State law.
OIG’s Fall 2025 Semiannual Report reflects an increased reliance on data analytics, coordinated enforcement, and program‑wide audits. Organizations operating in these areas should consider prospective, concurrent, and/or retrospective compliance auditing and monitoring, as well as targeted enhancements to address and potentially mitigate exposure as government scrutiny continues to intensify.
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