OIG: Medicare’s bundled payments for OUD treatments are inaccurate

Medicare could have saved over $300 million if CMS’ bundled payment rates for opioid use disorder (OUD) treatment services had reflected the types and frequency of services actually provided to enrollees, according to a recent Office of Inspector General (OIG) audit report.

CMS established Part B coverage of OUD treatment services furnished by opioid treatment programs (OTP) in 2020 and defined its methodology for bundling payments. The bundle combines payments for a drug component and a non-drug component, which includes the following services:

• The dispensing and administration of OUD medications
• Substance use counseling
• Individual group therapy
• Toxicology testing

To bill for this bundled payment, OTPs must provide at least one OUD treatment service for the episode of care.

The OIG set out to analyze CMS’ bundled payments for OUD treatment services and determine whether services provided to enrollees complied with certain Medicare requirements. The audit covered nearly 2.7 million Part B paid claim lines representing over $560 million in bundled payments with dates of services from January 1, 2020, through September 20, 2022, for OUD treatment services billed with Healthcare Common Procedure Coding System (HCPCS) codes G2067, G2068, and G2074. These three codes represented more than 99% of the total Part B bundled payments during the audit period, according to the OIG.

The OIG reviewed a random sample of 100 claim lines associated with 79 different OTPs. For each sample item, it determined the type of drug, types of OUD treatment services, and frequency of services to calculate a revised payment rate for these services. The OIG also reviewed whether the supporting documentation included a treatment plan, as well as whether the plan listed the frequency of services.

For 89 sample items, the bundled payments were higher than the OIG-calculated amounts based on the OUD services provided by OTPs to enrollees. For 49 sample items, OTPs provided only medication and medication-dispensing services, but Medicare made the full bundled payment.

Overall, the bundled payments for the 100 sample items totaled $21,216, whereas the OIG calculated the total payments to be $9,901. The OIG estimated that Medicare could have saved $301.5 million (53% of total payments) during the audit period if CMS’ bundling methodology reflected the types and frequency of treatment services provided to enrollees.

Ten of the 100 sample items included OUD treatment services that did not comply with Medicare requirements. Three did not have an associated treatment plan covering the episode of care, and seven did not indicate the frequency at which an enrollee was to receive behavioral health services in the plan. The OIG estimated that CMS made 266,446 bundled payments during the audit period for episodes of care without an associated treatment plan or with a treatment plan that did not comply with Medicare requirements.

The OIG provided the following recommendations to CMS:

• Use the audit results and consider revising its methodology for determining the non-drug component of the weekly bundled payment rates
• Consider developing, within its statutory authority, additional HCPCS codes for the weekly bundles (e.g., codes reflecting services provided at lower frequencies)
• Work with other agencies to monitor whether or not OTPs have properly documented OUD treatment services in enrollees’ treatment plans

Review CMS’ web pages on OTPs and OUD screening and treatment for more information.