Medicare Made $17.8 Million in Potentially Improper Payments for Opioid-Use-Disorder Treatment Services Furnished by Opioid Treatment Programs

Submitting OIG:

Department of Health & Human Services OIG

Date Issued:

Thursday, August 17, 2023

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-09-22-03005

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

Location(s):

United States

Type of Report:

Audit

Questioned Costs:

$17,817,121

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
92203005.pdf	2.02 MB

Recommendation Number	Recommendation Status	Significant Recommendation
23-A-09-103.01	Open	No
We recommend that the Centers for Medicare & Medicaid Services work with MACs to determine whether claims billed by OTPs for OUD treatment services complied with Medicare requirements.
23-A-09-103.02	Open	No
We recommend that the Centers for Medicare & Medicaid Services instruct MACs, based upon the results of this audit, to notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments, up to $17,817,121, in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
23-A-09-103.03	Open	No
We recommend that the Centers for Medicare & Medicaid Services instruct MACs to implement edits in their claims processing systems to prevent an OTP from being paid for: (1) a weekly bundle with a service date that was within a contiguous 7-day period of another weekly bundle's service date for the same enrollee at the same OTP or (2) two weekly bundles with the same service date for the same enrollee at the same OTP.
23-A-09-103.04	Open	No
We recommend that the Centers for Medicare & Medicaid Services revise its billing guidance to specify that OTPs should not bill add-on HCPCS codes for take-home supplies of medication for the same episode of care that was already covered by a weekly bundle that included medication, and instruct MACs to implement edits in their claims processing systems to identify improperly billed claims for take‑home medication.
23-A-09-103.05	Open	No
We recommend that the Centers for Medicare & Medicaid Services develop billing requirements for OTPs to include OUD diagnosis codes on claims for OUD treatment services to indicate that enrollees have OUD diagnoses, and consider working with MACs to implement a system edit to ensure that OTP payments are made for enrollees only when OUD diagnosis codes are included on claims.
23-A-09-103.06	Open	No
We recommend that the Centers for Medicare & Medicaid Services work with MACs to provide education on proper billing of intake activities to the 8 OTPs that billed 14 or more intake activity claims per enrollee during our audit period.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

23-A-09-103.01

Open

We recommend that the Centers for Medicare & Medicaid Services work with MACs to determine whether claims billed by OTPs for OUD treatment services complied with Medicare requirements.

23-A-09-103.02

Open

We recommend that the Centers for Medicare & Medicaid Services instruct MACs, based upon the results of this audit, to notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments, up to $17,817,121, in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

23-A-09-103.03

Open