OIG Work Plan: Agency to Focus on Collection of Medicare Advantage Ordering Provider Identifiers

OIG needs ordering provider identifiers in the Medicare Advantage (MA) encounter data to be available so it can use the data to identify and prevent potential fraud, waste and abuse. However, although OIG recommends, CMS doesn’t currently require MA organizations (MAOs) to submit National Provider Identifiers (NPIs) for ordering providers. In previous studies, OIG found that nearly two-thirds of records for clinical labs, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), imaging, and home health services reviewed did not include the NPI for the ordering provider.

Accordingly, the OIG plans to determine the extent to which MAOs obtain the NPIs of providers who order clinical lab services, DMEPOS, imaging services and home health services for MA enrollees and determine how MAOs that don’t obtain these identifiers are conducting routine monitoring, auditing and oversight of these types of services. The OIG will also provide updated information on how many MAOs voluntarily submit NPIs of providers who order clinical lab services, DMEPOS, imaging services and home health services to CMS.

Among the other 15 new Work Plan items for November, three may indirectly affect at least some lab providers and companies.

1. Additional Programming Code for Opioid Toolkit

 Issue: In June 2018, the agency issued Using Data Analysis To Calculate Opioid Levels and Identify Patients at Risk of Misuse or Overdose, a toolkit setting out steps for using prescription claims data to analyze patients’ opioid levels and identify certain patients at risk of opioid misuse or overdose.

OIG Action: The OIG will extend the toolkit’s reach beyond its current SAS programming code to include coding languages, R and SQL.

2. Medicaid Concurrent Eligibility

Issue: State Medicaid agencies pay managed care organizations (MCOs) capitated per-month, per-beneficiary payments. So, if a beneficiary in one state moves to another state, his/her Medicaid eligibility in the first state should end and the MCO in that state should no longer get payments for that beneficiary.

OIG Action: The OIG will check to see if states are making capitation payments to MCOs for beneficiaries after they’ve moved out of the state.

3. Medicare Payments for Stelara

Issue: Since 2016, total Medicare Part B physician payments for Stelara, an expensive drug used to treat certain autoimmune diseases that’s often self-injected by patients in their home, have increased substantially. Such a large increase in payments for a drug that wouldn’t typically be covered under Part B seems fishy and might betoken improper billing.

OIG Action: The OIG will:

• Determine if versions of Stelara that are typically self-injected meet the criteria for Medicare Part B coverage;
• Identify factors that may be causing the substantial growth in payments; and
• Determine whether claims for Stelara show evidence of improper billing by physicians.