The HHS Office of Inspector General does not wait for year-end to set its audit priorities. It adds new projects throughout the year, and many of them land directly on revenue cycle workflows such as coding, modifiers, refunds, and risk adjustment. For hospitals and physician groups, OIG compliance in RCM now means watching the Work Plan as closely as payer policy updates.
This guide covers the 2026 Work Plan items that matter most to revenue cycle teams, the updated 60-day overpayment rule, and a checklist to audit your own claims before OIG or a contractor does.
What the OIG Work Plan Means for Your Revenue Cycle
The Work Plan lists the audits and evaluations OIG is planning or conducting. OIG updates it throughout the year as new risks emerge, and a significant group of new audit projects was announced in March 2026 alone, targeting billing compliance, managed care integrity, and Medicaid financial stewardship.
A Work Plan item does not mean your organization is under review. However, it tells you where federal auditors, Medicare Administrative Contractors, and other reviewers are likely to focus. Those areas deserve an internal audit first.
2026 OIG Work Plan Items Revenue Cycle Teams Should Watch
| Work Plan Item | Announced | What to Audit Internally |
|---|---|---|
| E/M on the same day as minor surgery without modifier 25 | March 16, 2026 | Same-day E/M and procedure claims, and documentation of a separate service |
| Chronic care management (CCM) payments | March 16, 2026 | Time logs, consent, and the multiple chronic condition requirement |
| Medicare Advantage risk adjustment under V28 | January 15, 2026 | HCC diagnosis support, coding vendor practices, and data submissions |
| Inpatient neurostimulator implantation claims | March 16, 2026 | Inpatient status and medical necessity for device surgeries |
| Clinical diagnostic laboratory tests | April 15, 2026 | Lab orders, medical necessity, and genetic panel billing |
| Deductible and coinsurance refunds on adjusted or canceled claims | May 6, 2026 | Patient refunds after claim adjustments, reversals, and recoupments |
Two of these items deserve extra attention. First, CCM billing is under close review, with OIG assessing whether payments met Medicare requirements and the multiple chronic condition criteria. Second, risk adjustment coding remains a top target. OIG is analyzing Medicare Advantage coding patterns to see whether the savings expected from the V28 model were achieved, which puts coding and documentation practices at provider organizations in scope as well.
Recent OIG Findings Show What Is at Stake
OIG audits are producing large overpayment findings. In June 2026, OIG reported that CMS potentially overpaid Medicare Advantage organizations $462 million for payment year 2021 based on unsupported acute stroke diagnosis codes. In a separate 2026 report, OIG concluded that Medicare overpaid $636 million for neurostimulator implantation surgeries.
The pattern is consistent. The diagnosis or service was billed, but the documentation did not support it. You can read the full OIG acute stroke audit report to see how auditors test documentation against submitted codes.
For a deeper look at risk adjustment exposure, see our guide on how to protect RAF scores under CMS-HCC V28.
The 60-Day Overpayment Rule: What Changed
When an internal audit finds an error, the clock starts. Under a CMS final rule effective January 1, 2025, the 60-day period to refund an overpayment begins as soon as it is identified, even if the exact amount has not yet been calculated.
The rule does allow time to investigate. The 60-day return period can be suspended for up to 180 days while the provider conducts a timely, good faith investigation into related overpayments. After the suspension ends, the provider has the remainder of the 60 days to report and return the money. However, if no investigation takes place, or it is untimely or not in good faith, the overpayment must be returned within 60 days of identification. Duane Morris’s summary of the final rule explains how the timelines interact.
This connects directly to credit balances. Unresolved credit balances on Medicare accounts are often overpayments waiting to be identified. Our credit balance services help providers resolve them before they become compliance findings.
Modifier 25: The Most Common Physician Audit Risk
Modifier 25 remains one of the most reviewed modifiers in physician billing. The March 2026 Work Plan update confirmed that modifier 25 enforcement is still active and is coordinated with the Supplemental Medical Review Contractor’s nationwide review of modifier 25 use.
The risk runs in both directions. Missing modifier 25 can cause a valid E/M to deny. Overusing it on routine pre-procedure assessments creates overpayment risk. The documentation must show a significant, separately identifiable evaluation beyond the usual pre-procedure work.
OIG Compliance in RCM Checklist
Use this checklist to audit your revenue cycle against current OIG priorities:
✓ Audit same-day E/M and procedures — Sample claims with and without modifier 25 and test the documentation.
✓ Review CCM billing — Confirm consent, time thresholds, and two or more qualifying chronic conditions.
✓ Validate HCC diagnoses — Check that every risk-adjusting code has supporting documentation in the encounter.
✓ Reconcile patient refunds — Compare deductible and coinsurance collections against final claim adjustments.
✓ Resolve credit balances — Work Medicare and Medicaid credit balances within the 60-day window.
✓ Screen for exclusions — Check employees, providers, and vendors against the OIG List of Excluded Individuals/Entities on a regular schedule.
✓ Document your investigations — Record start dates and findings so you can show a timely, good faith review.
✓ Track Work Plan updates — Assign someone to review new OIG items each month and map them to your service lines.
How to Respond When an Audit Finds Errors
If an internal or external audit finds a problem, act quickly and in order:
Stop the error by fixing the coding rule, template, or workflow that caused it.
Define the scope by identifying related claims with the same cause.
Quantify the overpayment within the 180-day investigation window.
Report and return the overpayment to the payer through the appropriate process.
Educate and monitor with targeted training and follow-up audits.
Our clinical documentation integrity services help close the documentation gaps that most often lead to findings.
Conclusion
OIG compliance in RCM is no longer an annual exercise. The 2026 Work Plan targets modifier 25, chronic care management, risk adjustment, and refund practices. In addition, the updated 60-day rule leaves little room for slow investigations. The safest approach is to audit high-risk areas before OIG or a contractor does, and to resolve overpayments on a documented timeline.
MBW RCM provides medical coding and audit services that review claims against current OIG priorities, identify overpayment risk, and strengthen documentation before payers ask questions.
FAQs on OIG Compliance in RCM
What is the OIG Work Plan?
Which 2026 OIG Work Plan items affect physician practices most?
When must a Medicare overpayment be returned?
Do credit balances count as overpayments?
How often should providers screen for OIG exclusions?
Is Your Revenue Cycle Ready for an OIG Audit?
The best time to find a compliance gap is before an auditor does. MBW RCM can review your coding, modifiers, refunds, and credit balances against the 2026 OIG Work Plan and show where your organization may be exposed. Submit the form below to request a revenue cycle compliance review.