01-111 OIG Opioid Use Disorder Treatment Services Findings of Medical Review
Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B opioid use disorder (OUD) services billed on dates of service from January 1, 2022, through September 1, 2022. Below are the review results:
| Project ID | Project Title | Error Rate for Reviewed Claims | No Response to ADR Denials |
|---|---|---|---|
| 01-111 | OIG Opioid Use Disorder Treatment Services | 100% | 32% |
Background
The Office of Inspector General (OIG), published a report (A-09-22-03005) titled “Medicare Made $17.8 Million in Potentially Improper Payments for Opioid-Use-Disorder Treatment Services Furnished by Opioid Treatment Programs”. The OIG conducted an audit on 2.1 million Medicare Part B OUD claims and identified potentially up to $17.8 million improper payments to Opioid Treatment Programs (OTPs).
Reason for Review
In response to the OIG report, the SMRC was tasked to perform data analysis and conduct medical record reviews on claims billed with OUD Healthcare Common Procedure Coding System (HCPCS) codes G2067, G2068, G2069, G2074, G2078, and/or G2079 billed with date of service January 1, 2022, through September 1, 2022.
The SMRC conducted medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, sub-regulatory and coding guidance.
Common Reasons for Denial
- Medical Necessity for Overutilization
- Refer to Social Security Act (SSA) 1862, Internet Only Manual (IOM), 100-08, Medicare Program Integrity Manual (MPIM) Chapter (Ch.) 3, Section 3.6.2.2. The documentation provided does not support the medical necessity for this number of services or items within this timeframe. Documentation and billing history supported claims were billed with duplicate weekly bundles such as G2074 (weekly bundle not including medications) on the same day or within seven days of G2067 (weekly bundle, methadone) and/or the take home supply of medications were covered by other payments for take home supplies of medications or by payments for the weekly bundles that included medications.
- No Response to the Documentation Request
- Refer to IOM, Publication (Pub.) 100-08, MPIM, Ch. 3, Section 3.2.3.8. This requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request. The requested documentation was not submitted or not submitted timely to support reasonable and necessary criteria for OUD services.
- Incomplete and/or Insufficient Documentation Received
- Refer to 42 Code of Federal Regulations (CFR) 424.5(a)(6), SSA 1862(a)(1)(A), SSA 1833(e). The submitted documentation was insufficient or incomplete to perform a review of the services that were billed such as no medication administration record submitted, or the medication record was submitted but it was incomplete to support the dates of service on review.
References
Social Security Act (SSA), Title XI
- § 1135 Authority to Waive Requirements During National Emergencies
Social Security Act (SSA), Title XVIII
- § 1812(f) Scope of Benefits
- § 1815(a) Payment to Providers of Services
- § 1833(a)(1)(CC) Payment of Benefits, Opioid Use Disorder Treatment Services
- § 1833(e) Payment of Benefits
- § 1834(w) Special Payment Rules for Particular Items and Services, Opioid Use Disorder Treatment Services
- § 1861(jjj) Opioid Use Disorder Treatment Services; Opioid Treatment Program
- § 1861(s)(2)(A) Medical and Other Health Services
- § 1861(s)(2) (HH) Opioid Use Disorder Treatment Services and Supplies
- § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
- § 1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
- § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
- § 1893(b) Medicare Integrity Program
42 Code of Federal Regulations (CFR)
- § 8 Medication Assisted Treatment for Opioid Use Disorders
- § 410.67 Medicare Coverage and Payment of Opioid use disorder treatment services furnished by Opioid treatment programs
- § 411.15(k)(1) Any services that are not reasonable and necessary
- §424.5(a)(6) Basic Conditions and Sufficient Information
National Coverage Determination (NCD)
- NCD 130.6 Treatment of Drug Abuse (Chemical Dependency)
Public Law
- Public Law 115-271, October 24, 2018. Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act). Retrieved from PUBL271.PS (congress.gov)
Federal Register
- Federal Register. Volume (Vol.) 84, Number (No.) 221. Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollments Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule. November 15, 2019. Retrieved from CMS–1715–F and IFC
Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02
- Chapter (Ch.) 16 General Exclusion from Coverage
- Ch. 17 Opioid Treatment Program
IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 1 General Billing Requirements
- Ch. 23 Fee Schedule Administration and Coding Requirements
- Ch. 30, § 50 Advanced Beneficiary Notice (ABN) of Noncoverage
- Ch. 39 Opioid Treatment Programs (OTPs)
IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3 Verifying Potential Errors and Taking Corrective Actions
Other
- CMS. 2021 Medicare Physician Fee Schedule (PFS) Final Rule Summary for ASAM Members. January 2021. Retrieved from 2021-medicare-pfs-final-rule-summary_updated.pdf (windows.net)
- CMS. 2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F. Retrieved from CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F
- CMS Fact Sheet. Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. December 1, 2020. Retrieved from Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021 | CMS
- CMS. Opioid Treatment Program. Retrieved from Billing & Payment | CMS
- Medicare Learning Network (MLN) 8296732, May 2020. Opioid Treatment Programs (OTPs) Medicare Billing & Payment Fact Sheet. Retrieved from Opioid Treatment Programs (OTPs) Medicare Billing and Payment Fact Sheet (hhs.gov)
- Office of Inspector General (OIG). Medicare Made $17.8 Million in Potentially Improper Payments for Opioid-Use-Disorder Treatment Services Furnished by Opioid Treatment Programs. August 2023. Retrieved from (A-09-22-03005 )
- OIG. Opioid Overdoses and the Limited Treatment of Opioid Use Disorder Continue to Be Concerns for Medicare Beneficiaries. September 2022. Retrieved from (OEI-02-22-00390 )
- U.S. Food & Drug Administration. Information about Medication-Assisted Treatment (MAT). Retrieved form Information about Medication-Assisted Treatment (MAT) | FDA
Last Updated Oct 4, 2024