Kusserow on Compliance: OIG toolkit for calculating opioid levels and opioid misuse risk

The OIG toolkit provides detailed steps for using prescription drug claims data to analyze patients’ opioid levels and identify certain patients who are at risk of opioid misuse or overdose. It is based on the methodology that OIG has developed in its extensive work on opioids. This provides technical information to support the OIG’s public and private sector partners, such as Medicare Part D plan sponsors, private health plans, and State Medicaid Fraud Control Units. It is intended to assist OIG partners with analyzing their own prescription drug claims data to help combat the opioid crisis. It provides steps to calculate patients’ average daily morphine equivalent dose (MED), which converts various prescription opioids and strengths into one standard value. This measure is also called morphine milligram equivalent (MME). The toolkit includes a detailed description of the analysis and programming code that can be applied to the user’s own data. The resulting data can be used to identify certain patients who are at risk of opioid misuse or overdose. Users can also modify the code to meet their needs, such as identifying patients at other levels of risk. The toolkit has three chapters:

 

(1) Analysis of Prescription Drug Claims Data,

(2) Explanation of the Programming Code To Conduct the Analysis, and

(3) Programming Code.

 

Opioid abuse and overdose deaths are at epidemic levels in the United States. As one of the lead federal agencies fighting health care fraud, the OIG is committed to supporting public and private partners in its efforts to curb the opioid epidemic. These partners include Medicare Part D plan sponsors, other private health plans, State Medicaid Fraud Control Units, State prescription drug monitoring programs, and researchers. They can use this toolkit to analyze claims data for prescription drugs and identify patients who may be misusing or abusing prescription opioids and may be in need of additional case management or other follow-up. This toolkit can also be used to answer research questions about opioid utilization.

Copies can be obtained by contacting the Office of Public Affairs at Public.Affairs@oig.hhs.gov.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS releases Medicaid bulletin addressing opioid crisis

CMS has released an Informational Bulletin that provides states with information they can use when designing approaches to covering critical treatment services for Medicaid eligible infants with Neonatal Abstinence Syndrome (NAS), recognizing the serious problem of babies born with an addiction to drugs passed on from their mothers. CMS noted that Medicaid services can play a critical role in helping ensure access to treatment for these vulnerable infants who have Neonatal Abstinence Syndrome (NAS). Neonatal Abstinence Syndrome (NAS) is a postnatal drug withdrawal syndrome that occurs primarily among opioid-exposed infants shortly after birth. Experts consider NAS to be an expected and treatable result of women’s prenatal opioid or other substance use, although long term ramifications for the infants are still unknown. CMS noted an average of one infant born with NAS every 25 minutes in the United States and roughly 80 percent of infants treated for NAS receive their care through Medicaid. Appropriate treatment using the best evidence-based practices can help these infants withdraw from opioids and other substances and lead healthier lives. NAS treatment may occur not only in hospitals, but also in other settings.  In addition to Medicaid-covered treatment for infants, it is important for states to involve mothers and other caregivers in the infant’s care, as appropriate. The use of interventions like swaddling, quiet environments, little stimulation, skin-to-skin contact, and other environmental approaches are critical first-line care for these infants.

The CMS opioid technology guidance further advises states on which funding authorities may support health information technology efforts that could be used for the prevention and treatment of negative opioid outcomes. States may access enhanced federal funding to integrate innovative substance abuse treatment in areas facing provider shortages, particularly in rural areas, such as virtual treatment centers or remote counseling, into Medicaid care coordination technologies. They also describes how states can draw federal support for shared electronic care plans, which allows patients and providers to view and update a shared care plan describing goals for pain management regimens and counseling, and could complement Medication Assisted Therapy (MAT).

The letter describes how states might draw federal financing to support recommendations, such as integrating prescription drug monitoring systems data into EHRs and supporting interstate data sharing and electronic prescribing of controlled substances. In addition, the letter shows how states might use systems and funding to support advanced analytics for those looking to leverage data sources to create prediction models of patients at risk for opioid dependency and connect them with appropriate case management.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Four physicians charged in $200M prescription fraud scheme

A CEO and four physicians were charged in a superseding indictment in an investigation of a $200 million health care fraud scheme that involved a network of Michigan and Ohio pain clinics, laboratories, and other medical providers. Additional charges included wire fraud conspiracy, money laundering, and distribution of over 4.2 million medically unnecessary dosage units of controlled substances and medically unnecessary injections to Medicare beneficiaries, some of whom were addicted to narcotics. These included oxycodone, hydrocodone and oxymorphone. Some of the opioids were resold on the street.

When a medical review was made of the injection claims, it was found that 100 percent of the claims were not eligible for Medicare reimbursement. In order to conceal the continued billing of these fraudulent claims to Medicare, the defendants created new shell companies and continued to engage in the same billing of fraudulent claims, often changing only the name of the company on the door to the medical practice and/or inventing new suite numbers to conceal the continuation of the fraudulent practices at the same location. Defendants also owned a diagnostic laboratory to enable them to order medically unnecessary urine drug testing from the laboratory. When Medicare conducted a medical review of claims submitted by the laboratory, it determined that 95 percent of the claims were not eligible for Medicare reimbursement and ordered the diagnostic laboratory to repay $6.9 million in improper payments.

Another scheme involved money laundering in connection with a $6.6 million wire transfer and the withdrawal of $500,000 in cash, which was hidden in plastic bags in the closet of the house.  The indictment alleges that transferred proceeds derived from the conspiracy were used to allow the defendants to live an extravagant lifestyle and spend millions of dollars on luxury items—clothing from retailers like Hermes, rare Richard Mille watches, and exotic automobiles such as a Lamborghini and Rolls Royce Ghost. The proceeds were also used to purchase a mansion and other real estate in the Detroit, Michigan area and to sit courtside or in the first row of NBA basketball games, including the NBA Finals.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: HHS OIG Spring 2018 semi-annual report on sanctions and exclusions

1,678 administrative sanctions

1,588 individuals and entities excluded

$35.5 million in CMPL penalties/assessments

The OIG released its first semi-annual report for 2018 that included the number of administrative sanctions, exclusion actions taken, and CMPL penalties imposed. There were a total of 1,588 individuals and entities excluded from Medicare, Medicaid, and other Federal health care programs.  Most of the exclusions resulted from convictions for crimes relating to Medicare or Medicaid, for patient abuse or neglect, or as a result of license revocation. The OIG has a number of Administrative Sanction authorities whereby they have added steadily to the LEIE database.  In the last three years the OIG added over 10,000 exclusions to the List of Excluded Individuals and Entities (LEIE). The OIG also imposed 1,678 administrative sanctions and Civil Monetary Penalty Law penalties and assessments involving more than $35.5 million.

Comments from experts concerning sanctions

Tom Herrmann, JD, served for 20 years in the OIG Counsel’s Office, including being the Chief of the Administrative Litigation Branch, responsible for the litigation of cases involving the imposition of civil monetary penalties and program exclusions.  He explained that the OIG has been delegated the authorities to impose Civil Monetary Penalties, assessments, and program exclusion on health care providers and others determined to have engaged in defined wrongdoing. The effect of an OIG exclusion is that no payment may be made for any items or services furnished by an excluded individual or entity, or directed or prescribed by an excluded physician. In almost all instances where the OIG’s imposition of program exclusion or CMPs is appealed, it is upheld by an Administrative Law Judge (ALJ), the Departmental Appeals Board (DAB), and federal courts. As such, it is absolutely essential to have ongoing sanction-screening of anyone engaged by a health care organization.

Jillian Bower-Concepcion is another highly experienced health care compliance consultant, who has assisted scores of clients in meeting the sanction-screening obligations through the Compliance Resource Center (CRC). She notes the OIG posts their exclusions on their LEIE and calls for screening of all individuals and entities engaged by or with whom they do business against that listing. CMS has also been very aggressive in calling for sanction screening, not only of the LEIE, but Debarments posted by the GSA, as well as pressuring state Medicaid Directors to establish exclusion databases and mandate monthly screening by their enrolled providers. In order to meet screening mandates, it is almost a necessity to use a vendor search engine tools to assist in sanction-screening. This saves organizations from downloading the sanction databases of all the entities and developing their own search engine. Using a vendor for this purpose is a step in the right direction; however the bulk of the work remains with the organization to do screening and resolving potential “hits” remains with the organization. Altogether this can be a considerable effort and many organizations have to dedicate one or many employees to meet all these obligations.  Alternatively, many just outsource the entire process, including verification and certification of results to a vendor.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.