ENFORCEMENT

OIG Work Plan Monthly Review: January 2018

Opioid drug-related issues continue to command the lion’s share of OIG Work Plan attention, including two of this month’s six new items. While none of the new initiatives directly affect labs or lab services, five may have an indirect impact on at least some lab providers.

1. State Use of Automated Child Welfare Information System to Monitor Psychotropic & Opioid Drugs to Kids in Foster Care

Concern: To receive federal funding for child welfare services, States must have a plan for oversight and coordination of health care services for any child in foster care placement, including protocols for appropriate use and monitoring of psychotropic and opioid drugs for treating ADHD, schizophrenia, depression, bipolar disorder, anxiety and other mental health disorders.

OIG Action: The OIG will review State child welfare agency use of SACWIS, the Statewide Automated Child Welfare Information System, for monitoring psychotropic, ADHD and opioid medications prescribed to kids in foster care and the extent to which the ACF, Administration for Children and Families (ACF), ensures that kids in foster care receive medication in accordance with State requirements.

2. OIG Toolkit to Identify Patients at Risk of Opioid Misuse

Concern: In a July 2017 data brief (Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing (OEI-02-17-00250)), the OIG reported that in 2016, a half-million Medicare Part D beneficiaries received high amounts of opioids and nearly 90,000 of them were at serious risk of opioid misuse or overdose.

OIG Action: As a follow up to the data brief to help public and private sectors deal with the opioid epidemic, OIG will release a toolkit containing information about its analysis of a large dataset of opioid claims to produce patient-level opioid data and its calculation of Morphine Equivalent Dose (MED) levels for these patients.

3. Financial Impact of Health Risk Assessments & Chart Reviews on Medicare Advantage Risk Scores

Concern: Medicare Advantage (MA) organizations submit records of services provided to beneficiaries, including all diagnoses, during the previous year. CMS then uses this encounter data to adjust Medicare Part C monthly payments to ensure MA organizations get paid more for beneficiaries with higher expected costs. CMS also includes diagnoses from health risk assessments and chart reviews in calculating risk scores and risk-adjustment payments regardless of whether these diagnoses are supported by another service provided to the beneficiary during that year.

OIG Action: The OIG will do a study to determine the extent to which diagnoses solely generated by health risk assessments and chart reviews were associated with higher risk scores and higher MA payments, as well as the extent to which diagnoses removed by chart reviews were associated with lower risk scores and lower MA payments.

4. Potential Abuse & Neglect of Medicare Beneficiaries

Concern: Previous OIG reviews have found problems with the quality of care and the reporting and investigation of potential abuse or neglect of Medicare beneficiaries, including the disabled and elderly at group homes, nursing homes and skilled nursing facilities.

OIG Action: Based on analysis of treating medical facilities’ diagnoses, OIG will determine how widespread the potential abuse or neglect of Medicare beneficiaries is, as well as whether the potential abuse or neglect occurred at a medical facility or another location like the beneficiary’s home.

5. Questionable Billing for Off-the-Shelf Orthotic Devices

Concern: Since 2014, there’s been a 97% increase in claims for three off-the-shelf orthotic devices (L0648, L0650 and L1833) and a 116% increase in associated allowed charges. A Medicare Administrative Contractor (MAC) found that within its own jurisdiction improper payment rates were as high as 79% for L0648, 88% for L0650 and 91% for L1833. One of the MAC’s top concerns was lack of documentation of medical necessity in patients’ medical records.

OIG Action: OIG will study factors associated with questionable billing and billing trends for the three devices from 2014 to 2016 focusing on the extent to which Medicare beneficiaries were supplied the devices without an encounter with the referring physician within 12 months before their orthotic claim.

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