OIG identifies over $200 million in potential overpayments for drug testing services

Wednesday, March 15, 2023

Medicare could have saved nearly $216 million in payments for definitive drug testing services between 2016 and 2020 if proper program safeguards had been in place, according to a recent audit report by the Office of Inspector General (OIG).

The audit looked at approximately $3 billion in Medicare Part B payments made to 5,289 providers for definitive drug testing services. “Definitive drug testing identifies specific medications, illicit substances, and metabolite and reports the results in concentrations of drugs within a drug class,” according to the report.

Healthcare Common Procedure Coding System (HCPCS) codes G0480, G0481, G0482, G0483, and G0659 are used to bill for these services, and they are generally dependent on the number of tested drug classes. The report largely focused on HCPCS code G0483, which has the highest reimbursement amount and covers 22 or more drug classes.

The OIG identified 1,062 “at-risk” providers who billed G0483 for at least 75% of the definitive drug testing services they provided and that received at least $5,000 for those services during the audit period. Medicare Part B paid at-risk providers over $700 million for G0483 claims, according to the report.

To prevent and detect improper payments, CMS and Medicare contractors use safeguards such as coverage determinations, claims processing edits, oversight activities, and targeted provider-specific reviews, according to the report. However, the OIG said these safeguards were not adequate.

“If program safeguards had focused on at-risk payments to these providers, Medicare could have saved up to $215.8 million for our audit period,” according to the report.

The OIG also said that payments to at-risk providers may not have been reasonable and necessary. At-risk providers conducted presumptive drug testing to determine the number of drug classes to definitively test for less frequently than the other providers in the report.

In addition, the at-risk and other providers in the report had similar characteristics, including provider type, patient type, and testing frequency.

“This suggests that the at-risk providers may have been able to bill for definitive drug testing services using primarily procedure codes with lower reimbursement amounts, as the other providers did,” said the report.

Unlike previous OIG reports on this issue, this audit was not limited to services provided to beneficiaries with substance use disorders. Most services in this report were determined to be pain management treatments. Nearly 44% of at-risk providers billed ICD-10-CM code Z79.891 (long term [current] use of opiate analgesic), which the OIG categorized as pain management.

CMS only concurred with the first of the following four recommendations OIG provided in the report:

  • Expand program safeguards to prevent and detect at-risk payments to at-risk providers for HCPCS code G0483
  • Review at-risk payments made to at-risk providers during and after the audit period and recover any overpayments
  • Notify appropriate providers to exercise reasonable diligence to identify, report, and return any overpayments
  • Educate providers that received payments that did not comply with Medicare requirements

Revenue integrity professionals must ensure their organization is in compliance with Medicare payment requirements for drug testing services. Conduct internal audits on drug testing claims, particularly those for pain management treatment. Review best practices for billing HCPCS code G0483 and ICD-10-CM code Z79.891.

Editor’s note: Find more NAHRI coverage of OIG audits and reports here.