Significant federal workforce reductions and numerous government-wide programmatic changes headlined the 2025 news cycle. Under that backdrop, the U.S. Department of Health and Human Services, Office of Inspector General (OIG) fulfilled its annual statutory obligation by releasing its 2025 Top Management and Performance Challenges Report (Report).
The Report identifies five key challenge areas:
- financial integrity;
- Medicare and Medicaid;
- public health;
- beneficiary safety; and
- cybersecurity.
These key challenge areas remain largely unchanged from last year, but the Report offers important guidance to providers and key stakeholders on how and where the OIG will devote its resources in the year ahead, including:
- Preventing, Reducing, and Recovering Improper Payments and Controlling Costs by Ensuring Prudent Payments
- The OIG specifically highlights low barriers to market entry and reimbursement at rates higher than acquisition costs for skin substitute products, as well as for glucose monitors, as examples driving increased utilization that results in higher Medicare costs.
- Combatting Fraud, Waste, and Abuse
- Durable medical equipment, prescription drugs, hospice care, genetic and clinical laboratory testing, wound care, and treatment for substance use disorder remain on the OIG’s radar as items or services at a higher risk of fraud. The OIG also calls the Centers for Medicare and Medicaid Services (CMS) to more rigorously evaluate “the roles of for-profit ownership, vertical integration, and middlemen (e.g., pharmacy benefit managers)” to reduce the likelihood of fraud, waste, and abuse in health care. Similarly, the OIG emphasizes the need for greater transparency, accurate data, correct eligibility determinations, timely return of overpayments, and access to covered care in Medicaid programs.
- Protecting Patient Health and Safety
- Acknowledging that reducing patient harm remains a challenge, the OIG urges providers and program managers, particularly those in long-term care and skilled nursing facilities, to comply with health and safety requirements, appropriately vet and train staff, and identify and quickly correct weaknesses that put individuals at risk. In particular, the OIG emphasizes the importance of verifying the skills and credentials of providers and staff, as well as performing background checks to “prevent potential predators, and people otherwise disqualified,” from gaining access to vulnerable individuals.
Providers and other stakeholders operating in “high-risk” areas must remain vigilant. The start of the new year is the perfect time to evaluate the effectiveness of your compliance program and make any necessary adjustments to close gaps or fix shortcomings so that you can start 2026 with confidence.
The full Report is available here.
Should you have any questions regarding the above or wish to have a proposed arrangement evaluated for compliance with applicable laws, please contact the author, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].
