OIG Monthly Work Plan Review: April 2019

Among the 10 new Work Plan items this month, three may have potential ramifications for at least some labs.

Medicaid Managed Care Organization Denials

Issue: The State Medicaid agency and the federal government are responsible for financial risk for the costs of Medicaid services. Managed care organizations (MCOs) contract with state Medicaid agencies to ensure that beneficiaries receive covered Medicaid services. The contractual arrangement shifts financial risk for the costs of Medicaid services from the state Medicaid agency and the federal government to the MCO, which can create an incentive to deny beneficiaries’ access to covered services.

OIG Action: OIG review will determine whether Medicaid MCOs complied with federal requirements when denying access to requested medical and dental services and drug prescriptions that required prior authorization.

Review of Monthly ESRD-Related Visits Billed by Physicians or Other Qualified Healthcare Providers

Issue: Most physicians and other practitioners (e.g., clinical nurse specialists, nurse practitioners, or physician’s assistants) who manage the care of patients who receive outpatient dialysis services at end-stage renal disease (ESRD) facilities are paid a monthly capitation payment (MCP) for ESRD-related physician services. The MCP amount is based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or other practitioner can bill only one of three current procedural terminology (CPT) codes for ESRD-related visits of one per month, two to three per month, or four or more per month (CMS, Medicare Claims Processing Manual, Pub. No. 100-04, chapter 8, § 140.1).

OIG Action: The Comprehensive Error Rate Testing program’s special study of the Healthcare Common Procedure Coding System codes for ESRD-related services found that for some codes, approximately one-third of the payments for ESRD-related services were improper payments due to insufficient documentation, incorrect coding, or no documentation submitted (CMS, Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors, volume 5, issue 3, April 2015). OIG will review whether physicians or other qualified healthcare professionals billed monthly ESRD-related visits in accordance with federal requirements (Social Security Act, §§ 1815(a) and 1833(e)).

Audit of National Institutes of Health Information Technology and Interoperability Challenges Within Its Electronic Health Record System

Issue: The National Institutes of Health (NIH) comprises 27 separate institutes and centers and is the primary federal agency for conducting and supporting biomedical research to enhance health, lengthen life, and reduce illness and disability. Within NIH, certain institutes and centers provide direct patient care. NIH uses an electronic health records (EHR) system to help facilitate effective care.

OIG Action: The Departments of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 (Public Law No. 115-245) and its Accompanying Report directed that OIG examine operations of NIH. OIG will determine whether select EHR system controls are in place in accordance with federal requirements and assess EHR interoperability challenges.