CMS Clarifies Rules for OTP Medicare Billing Requirements

CMS Clarifies Rules for OTP Medicare Billing Requirements in Response to $17.8M Improper Payments

A recent report by the U.S. Department of Health & Human Services’ (HHS) Office of the Inspector General (OIG) found that payments made to Opioid Treatment Providers (OTPs) for Opioid Use Disorder (OUD) treatment services may not have complied with Medicare requirements. The OIG suspects that up to $17.9 million in potentially improper payments were made to OTPs, in the following categories:

$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.
$1 million in payments for intake activities that occurred a total of 14 or more times for the same enrollee during our audit period.

The OIG found one factor that contributed to these incorrect payments to be the fact that CMS did not instruct their Medicare Administrative Contractors (MACs) to implement system edits that would prevent OTPs from being paid for OUD treatment services that are covered by other Medicare payments for the same enrollee at the same OTP. As such, CMS has released a new Compliance Bulletin providing guidance for OTP Billing & Payment for OUD Services. This bulletin clarifies the OTP G-codes for intake activities, bundled payment guidance, appropriate billing forms for institutional and professional providers, guidance for submitting claims, payment rate information, and supplemental resources.

OTPs are encouraged to review CMS’ OTP Medicare Billing & Payment Guidance document to ensure that they understand the correct ways to bill Medicare for OUD services and the correct G-codes to use for treatment.