OIG Work Plan Monthly Review: June 2018

None of the eight new Work Plan items for June directly address labs and lab testing. However, five of the items may indirectly labs that are part of larger health networks participating in the activities and programs covered.

1. Medicare Part B Payments for ESRD Dialysis Services

Issue: Previous OIG review found problems with Medicare payments for outpatient end-stage renal disease treatments including payments for services:

• For services not furnished or documented;
• For which there was insufficient medical necessity documentation;
• That were not ordered by a physician; and
• That were ordered by a physician not treating the particular patient.  

OIG Action: The OIG plans to review Part B ESRD dialysis claims to see if the billed services met all Medicare requirements.

2. Medicare Part D Denials & Appeals

Issue: The Medicare Part D capitated payment model may give insurers an incentive to deny beneficiaries access to services or payment. But there is also a multi-layered appeals system that beneficiaries can use if they are denied Part D prescriptions and payments.

OIG Action: The OIG will review national trends and CMS's oversight of prescription drug denials in Part D during 2014-2016 to determine the extent to which denials that have been appealed to each level of review were overturned. The agency will also look at variations in appeals and overturned denials across Part D contracts and evaluate CMS's efforts to monitor and address inappropriate denials in Part D.

3. Inappropriate Medicare Advantage Denials of Services & Payment

Issue: The capitated payment model that Medicare Advantage uses may give managed care plans an incentive to inappropriately deny access to, or reimbursement for, health care services.

OIG Action: The OIG will conduct medical record reviews to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare and try to determine the reasons for any inappropriate denials and the types of services involved.

4. Review of Home Health Claims for Services with 5 to 10 Skilled Visits

Issue: Home health agencies receive Low Utilization Payment Adjustments (LUPAs) if they provide four or fewer covered skilled service provider visits in an episode. But after a fifth visit is provided, the HHA instead gets a full 60-day payment based on episode of care.

OIG Action: Since the OIG has not reviewed payments for LUPA, it will review supporting documentation to determine whether home health claims with 5 to 10 skilled visits in a payment episode in which the beneficiary was discharged home met the conditions for coverage and were adequately supported as required by federal guidance.

5. ACO Strategies for Reducing Spending and Improving Quality

Issue: The Medicare Shared Savings Program (MSSP) introduced accountable care organizations into Medicare to promote accountability of hospitals, physicians and other providers responsible for a patient population, coordinate items and services, encourage investment in infrastructure and redesign care processes for high-quality and efficient service delivery.

OIG Action: The OIG will identify ACO strategies aimed at:

• Reducing spending and improving care in different service areas, such as hospitals and nursing homes;
• Working with physicians and engaging beneficiaries;
• Managing the care of beneficiaries needing high-cost, complex care;
• Addressing behavioral health and social needs; and
• Using data and technology.