ENFORCEMENT

OIG Work Plan Monthly Review: November 2017

The OIG added four new items to its Work Plan this month, all of which have potential indirect effects on clinical labs involved in providing the targeted services.

1. Opioids in Medicaid: Concerns about Extreme Use and Questionable Prescribing

Concern: Medicaid beneficiaries are particularly vulnerable to opioid abuse and overdose deaths because they are more likely to have chronic conditions and comorbidities requiring pain relief, especially if they qualify for Medicaid due to a disability.

What OIG Will Investigate: The OIG will identify cases in which beneficiaries may have gotten extreme amounts of opioids through Medicaid as a result of shopping for doctors, pharmacies or other prescribers. The agency will use the results as baseline data for identifying both beneficiaries who receive extreme amounts of opioids and providers with questionable opioid prescribing patterns.

2. Medicaid Services Delivered Using Telecommunication Systems

Concern: The OIG notes that there has been a “significant increase” in Medicaid claims for telemedicine, telehealth and telemonitoring services.

What OIG Will Investigate: The OIG will review selected States’ Medicaid payments for tele-services to ensure that they are on the level. Items the agency is likely to check:

  • Qualifications and use of facility site codes by the originating site;
  • Whether all services billed were covered;
  • Use of POS codes and modifiers by the distant site;
  • Whether the rendering provider was an eligible distant site provider;
  • Compliance with geographic location requirements for tele-services; and
  • Whether the technology used met the applicable audio and visual requirements.

3. Medicare Claims on Which Hospitals Billed for Severe Malnutrition

Concern: There are three Diagnosis Related Groups (DRGs) for hospital inpatient treatment of malnutrition based on the severity of the condition—mild, moderate or severe. Severe malnutrition is classified as a major complication or comorbidity (MCC). And adding an MCC to a Medicare claim can result in a higher Medicare payment because the claim is coded at a higher DRG.

What OIG Will Investigate: The OIG will review whether providers are using the proper DRG codes for severe malnutrition to ensure that no upcoding is taking place. 

4. Use of Funds by Medicaid Managed Care Organizations

Concern: Managed care accounted for over 40% of total Medicaid payments in 2015 and that rate continues to grow. Capitation in which Managed Care Organizations (MCOs) receive a pre-determined rate for each enrollee regardless of actual services rendered is one of the methods Medicaid uses to control Medicaid costs.

What OIG Will Investigate: The OIG will review whether Medicaid MCOs are spending their capitation payments to provide quality medical services, including lab tests, to enrollees.

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