The Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) recently released the results of an audit showing that the state of New York improperly claimed an estimated $39.3 million in Medicaid reimbursement for opioid treatment program (“OTP”) services during the audit period. OIG is recommending that New York refund that $39.3 million, as well as implement procedures to prevent such claims going forward.
OTPs provide medication-assisted treatment for patients diagnosed with an opioid use disorder. Patients in OTPs must also undergo counseling and behavioral therapy. OTPs must be certified by HHS’ Substance Abuse and Mental Health Services Administration (“SAMHSA”). The audit was part of OIG’s oversight of the “integrity and proper stewardship” of Federal funds directed to the OTPs.
The OIG audit covered 10.7 million claims for OTP services provided in the New York City metro area from 2014 through 2017 to determine compliance with Federal and state Medicaid requirements. These claims accounted for over $445 million in Medicaid claims, of which the Federal share accounted for $272 million. OIG reviewed a random sample of 150 claims for compliance with Federal and state requirements. In addition, OIG identified 6,700 potentially duplicate claims, and selected a sample of 598 of those claims for further review.
The audit found the following deficiencies: central registry verifications not adequately documented, diagnosis of opioid addiction not documented, medical records not signed, services not documented or supported, treatment plans missing or not reviewed, toxicology tests not documents, and services not identified in treatment plan.
OIG determined that these improper claims occurred because providers –
- Failed to maintain or provide proper documentation of OTP services,
- Did not ensure that services were provided according to the requirements of Medicaid beneficiaries’ treatment plans, and
- Did not maintain the required signature for OTP services.
OIG also noted that, while New York inspects providers to verify compliance with Medicaid requirements, these compliance inspections failed to prevent the errors and the resulting improper claims.
In response, New York did not take a position on OIG’s recommendations, but did note that it will take actions to address the OIG’s concerns, including having the New York Office of the Medicaid Inspector General review the claims in the report and determine how to address those claims. In addition, New York will issue guidance to OTP providers reminding of the compliance activities necessary to comply with Federal and State laws pertaining to Medicaid reimbursement for OPT services.