OIG Monthly Work Plan Review: August 2019

Of the 12 new items in the OIG's Work Plan this month, six indirectly impact lab providers and services.

Medicare Payments of Positive Airway Pressure (PAP) Devices for Obstructive Sleep Apnea (OSA) Without Prior Sleep Study

Issue: OIG analysis of the 2017 Comprehensive Error Rate Testing (CERT) program for positive airway pressure (PAP) device payments revealed overpayments of up to $566 million potentially attributable to improper claims for PAP devices used to treat OSA for beneficiaries who didn't have a positive diagnosis of OSA based on an appropriate sleep study.

OIG Action:  OIG will examine Medicare payments to durable medical equipment providers for PAP devices used to treat OSA to determine whether an appropriate sleep study was conducted in accordance with "reasonably necessary" coverage criteria.

Review of Medicare Diagnosis-Related Group (DRG) Window Policy

Issue: Lab and other outpatient services directly related to inpatient admission are considered part of the inpatient payment and thus not separately payable by Medicare. The DRG window policy defines when CMS deems outpatient services to be an extension of inpatient admissions, including services that are: (1) provided within the 3 days immediately before an inpatient admission to an acute-care hospital; (2) diagnostic services or admission-related nondiagnostic services; and (3) provided by the admitting hospital or by an entity wholly owned or operated by the admitting hospital.

OIG Action: OIG will determine the number of admission-related outpatient services that weren't covered by the DRG window policy in 2018, including services provided before the start of the DRG window and services provided at hospitals sharing a common owner, and figure out how much Medicare and beneficiaries would have saved if the DRG window policy had been updated to include more days and other hospital ownership structures. The agency will also interview CMS staff to identify other payment models that CMS could use to pay for outpatient services related to inpatient admissions.

Opioids in Medicaid: Review of Extreme Use and Overprescribing in the Appalachian Region

Issue: While opioid abuse and overdose deaths are a national crisis, the problem is particularly acute in the Appalachian region. In 2017, the opioid overdose death rate was 72% higher in Appalachian counties than non-Appalachian counties. This is of particular concern for Medicaid beneficiaries, who are more likely to have chronic conditions and comorbidities that require pain relief, especially beneficiaries who qualify through a disability.

OIG Action: OIG will identify beneficiaries who received excessive amounts of opioids through Medicaid, beneficiaries who appear to be doctor- or pharmacy-shopping, and prescribers associated with these beneficiaries.

Medicare Market Shares for Diabetic Testing Strips (DTS) from April to June 2019

Issue: Section 1847(b)(10)(B) of the Social Security Act (the Act) requires OIG to study and report on the Medicare market share of DTS before each round of the Medicare competitive bidding program. CMS uses these data briefs to ensure that bidding suppliers meet the 50-percent rule (section 1847(b)(10)(A) of the Act). Section 50414 of the Bipartisan Budget Act of 2018 amended section 1847(b)(10)(A) by requiring that, for bids to furnish DTS on or after Jan. 1, 2019, CMS must use both mail order and non-mail order data when assessing compliance with the 50-percent rule. Previously, OIG reported only mail order data in its data briefs used for CMS's assessment of compliance with the 50-percent rule.

OIG Action: For this series, the first data brief will determine the Medicare market share of mail order DTS from April through June 2019. The second data brief will determine the Medicare market share of non-mail order DTS for the same 3-month period. This will be the fifth series of OIG data briefs describing the Medicare market share of DTS that OIG has produced since 2010 and the second series that will include both mail order and non-mail order DTS data.

Medicare Part B Services to Medicare Beneficiaries Residing in Nursing Homes During Non-Part A Stays

Issue: Medicare pays physicians, non-physician practitioners, and other providers for services rendered to Medicare beneficiaries, including those residing in nursing homes (NHs). Most of these Part B services aren't subject to consolidated billing; accordingly, each provider submits a claim to Medicare. Since the 1990s, OIG has identified problems with Part B payments for services provided to NH residents. An opportunity for fraudulent, excessive, or unnecessary Part B billing exists because NHs may not be aware of the services that the providers bill directly to Medicare, and because NHs provide access to many beneficiaries and their records.

OIG Action: OIG will determine whether Part B payments to Medicare beneficiaries in NHs are appropriate and whether NHs have effective compliance programs and adequate controls over the care provided to their residents.

Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care

Issue: While all 50 States and the District of Columbia currently provide some Medicaid coverage of telehealth, there's limited information about how States use telehealth to provide behavioral health services to Medicaid managed care enrollees.

OIG Action: OIG will analyze how selected States and managed care organizations (MCOs) use telehealth to provide behavioral healthcare. It will also review selected States' monitoring and oversight of MCOs' behavioral health services provided via telehealth and identify States' and MCOs' practices on how to maximize the benefits and minimize the risks of providing behavioral healthcare via telehealth.