OIG Monthly Work Plan Review: August 2018

Of the 12 new Work Plan items, four have direct implications for labs and billing of lab tests.

1. Medicare Payments for Clinical Diagnostic Laboratory Tests in 2017: Year 4 of Baseline Data

Issue: Medicare is the largest payer of laboratory service in the nation. Medicare Part B covers most lab tests and pays 100 percent of allowable charges; Medicare beneficiaries do not pay copayments or deductibles for lab tests. In 2016, Medicare paid $6.8 billion for lab tests, accounting for approximately 2 percent of all Part B payments.

OIG Action: The Protecting Access to Medicare Act of 2014 requires OIG to publicly release an annual analysis of the top 25 laboratory tests by expenditures under Title XVIII of the Social Security Act. In accordance with the Act, OIG will publicly release an analysis of the top 25 laboratory tests by expenditures for 2017.

2. Blood Lead Screen Tests, Follow-Up Services and Treatment for Medicaid-Enrolled Children

Issue: There is no safe level of lead exposure for children. In the absence of timely screening, follow-up services, and treatment, children remain vulnerable to cognitive deficiencies associated with lead screening. Medicaid-enrolled children are required to receive blood lead screenings. Under the Early and Periodic Screening, Diagnostic, and Treatment program, children are also entitled to receive follow-up services and treatment for conditions identified through screenings (e.g., elevated blood lead levels (EBLLs).

OIG Action: Although previous OIG reports identified low rates of lead screenings, an evaluation of follow-up services for Medicaid-enrolled children with EBLLs has not been done. OIG will identify the percentage of children under 26 months of age who (1) received required blood lead screenings, (2) had EBLLs, and (3) received needed follow-up services and treatment. Additionally, OIG will determine why children with EBLLs did not receive screening, follow-up services, and treatment—and the extent to which the Centers for Medicare & Medicaid Services (CMS) provided guidance and technical assistance to states.

3. Medicare Market Shares of Mail Order Diabetic Test Strips from April-June 2018

Issue: The OIG is required to report on the Medicare market share of both mail order and non-mail-order diabetic test strips (DTS) before each round of the Medicare competitive bidding program, pursuant to section 50414 of the Bipartisan Budget Act of 2018.

OIG Action: In the first of two data briefs, OIG will determine the Medicare market share of mail order DTS for the three-month period of April through June 2018. The second data brief will determine the Medicare market share of non-mail-order DTS for the same three-month period. The data will help CMS determine the relative Medicare market share of various DTS in the mail order and non-mail-order markets. These data briefs represent OIG’s third round of DTS Medicare market share reports since 2010, but this is the first series of reports that will include non-mail-order DTS data.

4. Physician Billing for Critical Care Evaluation and Management Services

Issue: Critical care, whether delivered in a critical care area such as a coronary, respiratory or intensive care unit, or the emergency department is payable under Medicare as long as the care provided meets the definition of critical care, i.e., the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient. Critical care is exclusively a time-based code in which physicians are paid based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient’s care and must be immediately available to the patient.

OIG Action: OIG will do a review to determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.