Deeper Than the Headlines: New OIG Work Plan Items Added in July 2018

The OIG has added new work plan items in July 2018. I’ve detailed the items I find the most interesting below. Let me know what you think in the comments section and feel free to ask any questions you might have about the items listed below.

Radiation Therapy Planning Services

3-Dimensional Conformal Radiation Therapy (3D-CRT) is a radiation therapy technique that allows doctors to sculpt radiation beams to the shape of a patient's tumor. 3D-CRT is provided in two treatment phases: planning and delivery. Hospitals bill Medicare for developing a 3D-CRT treatment plan using CPT code 77295. Automated prepayment edits prevent additional payments for separately billed radiation planning services if they are billed on the same date of service as the 3D-CRT treatment plan. However, Medicare allows additional payments if they are billed on a different date of service (e.g., 1 day before). For a form of radiation like 3D-CRT, Medicare requirements prohibit payments for separately billed radiation planning services when they are billed on a different date of service. The OIG is planning to determine the extent of potential savings to Medicare if it had implemented the same requirements for 3D-CRT planning services.

Post-Operative Services in the Global Surgery Period

MACRA requires CMS to collect data on post-operative services included in global surgeries and requires OIG to audit and verify a sample of the data collected. For this work plan item, the OIG plans to review a sample of global surgeries to determine the number of post-operative services documented in the medical records and compare it to the number of post-operative services reported in the data collected by CMS. OIG will verify the accuracy of the number of post-operative visits reported to CMS by physicians and determine whether global surgery fees reflected the actual number of post-operative services that physicians provided to beneficiaries during the global surgery period.

Increased Payments for Transfer Claims with Outliers

While the transfer rule reduces the Diagnosis Related Group (DRG), Disproportionate Share Hospital (DSH), and Indirect Medical Education (IME) payments on a Medicare beneficiary's claim, the methodology for calculating cost outlier payments can result in such payments being higher than what would have been paid in a non-transfer context. Under the transfer rule, CMS reduces the DRG payment by applying a graduated per diem payment on the Medicare claim of the hospital transferring the patient to another setting early in the patient's hospital stay. Because DSH and IME payments are determined as a percentage of the reduced DRG payment, they are also reduced.

In contrast, by reducing the threshold above which a claim qualifies as an outlier, the application of the outlier methodology can result in an increase in the outlier payment in transfer cases. OIG plans to produce a report describing the extent to which additional Medicare outlier payments negate the reduction in DRG, DSH, and IME payments of transfer claims.

SAMHSA's Oversight of Accreditation Bodies for Opioid Treatment Programs

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 2.5 million people have an opioid use disorder related to prescription pain relievers and/or heroin. Medication-Assisted Treatment (MAT), provided by opioid treatment programs (OTPs), is a significant component of the treatment protocols for opioid use disorder and plays a large role in combating the opioid epidemic in the United States.
SAMHSA issued final regulations to establish an oversight system for the treatment of substance use disorders with MAT. These regulations (found at 42 CFR Part 8) established procedures for an entity to become an approved accreditation body, which evaluates OTPs and ensures SAMHSA's opioid dependency treatment standards are met. OIG’s objective will be to determine whether SAMHSA's oversight of accreditation bodies complied with Federal requirements. This series of audits will include SAMHSA-approved accrediting bodies that have accredited OTPs.

As usual, if your organization is involved in these types of services, it is probably wise to proactively review these or similar activities within your organization.

Questions or Comments?