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

What OIG Found

Payments made to opioid treatment programs (OTPs) for opioid use disorder (OUD) treatment services may not have complied with Medicare requirements. Specifically, Medicare made up to $17.8 million in potentially improper payments to OTPs, consisting of the following payments: $10.4 million for claims for which a bundled payment was made for a weekly episode of care (i.e., a weekly bundle) that was covered by a payment for another weekly bundle for the same enrollee at the same OTP; $5.1 million for take-home supplies of medication (i.e., methadone or buprenorphine) that were covered by other payments for take-home supplies of medication or by payments for weekly bundles that included medication; $1.3 million for OUD treatment services that were claimed without an OUD diagnosis; and $1 million in payments for intake activities that occurred a total of 14 or more times for the same enrollee during our audit period. These potentially improper payments occurred because, among other causes, CMS did not instruct Medicare Administrative Contractors (MACs) to implement system edits to prevent OTPs from being paid for OUD treatment services covered by other Medicare payments for the same enrollee at the same OTP.

What OIG Recommends and CMS Comments

We made six recommendations to CMS, including that CMS: (1) work with MACs and other Medicare contractors to determine whether claims billed by OTPs for OUD treatment services complied with Medicare requirements; (2) instruct MACs, based upon the results of this audit, to notify appropriate providers so that the providers can exercise reasonable diligence to identify, report, and return any overpayments, up to $17.8 million, in accordance with the 60-day rule; and (3) instruct MACs to implement edits in their claims processing systems to prevent an OTP from being paid for two weekly bundles with the same service date for the same enrollee at the same OTP.

CMS concurred with four of six recommendations and provided information on actions that it planned to take to address these recommendations. CMS did not explicitly state whether it concurred with one recommendation. CMS did not concur with another recommendation and stated that our audit alone is not sufficient basis upon which CMS can support a 60-day-rule notice of overpayments to identified providers. We maintain that our recommendations are valid because we believe that this audit report constitutes credible information of potential overpayments.

Filed under: Centers for Medicare and Medicaid Services