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More Than 90 Percent of the New Hampshire Managed Care Organization and Fee-for-Service Claims for Opioid Treatment Program Services Did Not Comply With Medicaid Requirements

Why OIG Did This Audit

The Medicaid program pays for opioid treatment program (OTP) services. Prior Office of Inspector General (OIG) audit reports have identified OTP services as vulnerable to fraud, waste, and abuse.

Our objective was to determine whether New Hampshire claimed Medicaid reimbursement for OTP services in accordance with Federal and State requirements.

How OIG Did This Audit

We reviewed New Hampshire's monitoring and oversight of the OTP providers (providers), including compliance with Federal and State requirements, to determine whether: (1) counseling hour and toxicology testing requirements were met, (2) initial treatment plans were prepared, (3) treatment plans were reviewed as required, and (4) the OTP service was provided. We reviewed 100 randomly sampled claim lines of service from the 1,458,896 lines of service between July 1, 2016, to June 30, 2019, for which New Hampshire paid $16.2 million.

What OIG Found

New Hampshire claimed Medicaid reimbursement for OTP services that did not comply with Federal and State requirements. Of the 100 OTP services we sampled, 6 complied with Federal and State requirements, but 94 did not meet applicable Federal and State requirements. These deficiencies occurred because New Hampshire did not have the resources to oversee providers and enforce the OTP requirements. Providers said high personnel turnover, difficulty attracting and retaining personnel, and difficulty keeping patients engaged in counseling services contributed to the lack of adherence to State requirements. Furthermore, New Hampshire did not always provide guidance regarding State OTP requirements.

On the basis of our sample results, we estimated that New Hampshire improperly claimed at least $7.9 million in Federal Medicaid reimbursement for OTP services during our audit period.

What OIG Recommends and New Hampshire Comments

We made several recommendations to the New Hampshire Department of Health and Human Services, including that it: (1) refund $7.9 million to the Federal Government, (2) take steps to ensure that providers comply with Federal and State requirements for providing and claiming Medicaid reimbursement for OTP services, and (3) improve communication with providers regarding the State requirements for opioid use disorder treatment and provide written confirmation about whether offsite counseling may be included as a required counseling service.

In written comments on our draft report, New Hampshire agreed with our recommendations and indicated that it will work with CMS to refund $7,943,271 to the Federal Government. It also stated that it continues to work with Medicare contractors on provider oversight of substance use disorder treatments. New Hampshire stated that it recently completed a training with all of the OTP providers that included information on the allowability of offsite counseling. Lastly, New Hampshire said that its Bureau of Drug and Alcohol Services will perform a clinical audit of the OTPs in July 2022.

Filed under: Centers for Medicare and Medicaid Services