How many Medicare beneficiaries receive medications for opioid use disorder?
About 1 million Medicare beneficiaries were diagnosed with opioid use disorder in 2020. Yet less than 16 percent of these beneficiaries received medication to treat their opioid use disorder, raising concerns that beneficiaries face challenges accessing treatment.
How many Medicare Advantage organizations overturn denials each year?
When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014-16, overturning approximately 216,000 denials each year.
Does Medicare Advantage have a capitated payment model problem with Maos?
A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for MAOs to inappropriately deny access to services and payment in an attempt to increase their profits.
What is an MAO that misuses Medicare dollars?
An MAO that inappropriately denies authorization of services for beneficiaries, or payments to health care providers, may contribute to physical or financial harm and also misuses Medicare Program dollars that CMS paid for beneficiary healthcare.
Is the OIG authorized to impose exclusions on providers?
OIG has the authority to exclude individuals and entities from Federally funded health care programs pursuant to section 1128 of the Social Security Act (Act) (and from Medicare and State health care programs under section 1156 of the Act) and maintains a list of all currently excluded individuals and entities called ...
What is an exclusion by the OIG?
An OIG Exclusion is a final administrative action by the Office of the Inspector General (OIG) that prohibits participation in any Federal Health Care Program. Exclusions are imposed because the individual or entity is found to pose unacceptable risks to patient safety and/or program fraud.
What does the OIG assist with in the healthcare industry?
Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation's efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.
What percentage of Medicare appeals are successful?
For the contracts we reviewed for 2014-16, beneficiaries and providers filed about 607,000 appeals for which denials were fully overturned and 42,000 appeals for which denials were partially overturned at the first level of appeal. This represents a 75 percent success rate (see exhibit 2).
What does OIG look for?
What is an OIG Search? An OIG Search identifies individuals or entities that have been excluded from participation in Medicare, Medicaid or other federal healthcare programs. When/if an individual or an entity is restored back to the program and the exclusion is lifted, they will be removed from the list.
What are OIG guidelines?
OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to ...
What happens when OIG investigation?
Q: What happens when an investigation is complete? A: Generally, when an investigation is complete, OIG will produce a report based upon relevant witness interviews, records, and other evidence. The report will be reviewed within OIG to ensure that it is fact-based, objective, and clear.
What is a Medicare OIG audit?
Under this authority, OIG conducts audits of internal CMS activities, as well as activities performed by CMS grantees and contractors. These audits are intended to provide independent assessments of CMS programs and operations and to help promote economy and efficiency.
What are the 3 statutory goals of an OIG?
OIG provides independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS.
Which health insurance company denies the most claims?
In its most recent report from 2013, the association found Medicare most frequently denied claims, at 4.92 percent of the time; followed by Aetna, with a denial rate of 1.5 percent; United Healthcare, 1.18 percent; and Cigna, 0.54 percent.
How do I fight Medicare?
Fill out a "Redetermination Request Form [PDF, 100 KB]" and send it to the company that handles claims for Medicare. Their address is listed in the "Appeals Information" section of the MSN. Or, send a written request to company that handles claims for Medicare to the address on the MSN.
What can Medicare beneficiaries appeal?
You can file an appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage Plan, other Medicare health plan, or Medicare drug plan. Section 1: What can I appeal, and how can I appoint a representative?
What does Exclusion List mean?
In a nutshell, the OIG's LEIE (Exclusion List) is where individuals and entities currently excluded from participation in Medicare, Medicaid and all other Federal health care programs, can be found.
What is OIG GSA exclusion list?
In simplest terms, a government exclusion list is a roster of individuals and organizations that are not eligible to participate in federal or state contracts due to criminal behavior or misconduct. These lists are maintained by state or federal agencies and updated regularly.
How do I get rid of OIG exclusion list?
How to Get Off the OIG Exclusion List?Send a written request containing: Individual's or entity's full name (if excluded under a different name, also include that name) ... Fax or email the request to the OIG at (202) 691-2298 or sanction@oig.hhs.gov.If eligible, the OIG will send statement and authorization forms.
How long do OIG exclusions last?
For these exclusions, a Notice of Exclusion is the first notification sent. Exclusions are effective 20 days after the Notice of Exclusion is mailed, and notice to the public is provided on OIG's website. The exclusion may be appealed to an ALJ, and any adverse decision may be appealed to the DAB.
What are the vulnerabilities of hospices?
These vulnerabilities include insufficient reporting requirements for hospices, limited reporting requirements for surveyors, and barriers that beneficiaries and caregivers face in making complaints. Also, these hospices did not face serious consequences for the harm described in this report. Specifically, surveyors did not always cite immediate jeopardy in cases of significant beneficiary harm and hospices' plans of correction are not designed to address underlying issues. In addition, CMS cannot impose penalties, other than termination, to hold hospices accountable for harming beneficiaries.
What is hospice care?
Hospice care can provide great comfort to beneficiaries, their families, and caregivers at the end of a beneficiary's life. Medicare hospice beneficiaries have the right to be free from abuse, neglect, and other harm.
Does hospice provide needed services?
As part of a recent portfolio, OIG found that hospices did not always provide needed services to beneficiaries and sometimes provided poor quality care.
How many beneficiaries does Medicare Advantage cover?
Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers.
What percentage of denials were appealed in 2014-16?
During 2014-16, beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.
How many cases of harm to hospice beneficiaries?
This report features 12 cases of harm to beneficiaries receiving hospice care. We examined each case to identify vulnerabilities that could have led to the harm and to determine how such harm could be prevented in the future. Some instances of harm resulted from hospices providing poor care to beneficiaries and some resulted from abuse by caregivers or others and the hospice failing to take action. These cases reveal vulnerabilities in the Centers for Medicare & Medicaid Services’ (CMS’s) efforts to prevent and address harm. These vulnerabilities include insufficient reporting requirements for hospices, limited reporting requirements for surveyors, and barriers that beneficiaries and caregivers face in making complaints. Also, these hospices did not face serious consequences for the harm described in this report. Specifically, surveyors did not always cite immediate jeopardy in cases of significant beneficiary harm and hospices’ plans of correction are not designed to address underlying issues. In addition, CMS cannot impose penalties, other than termination, to hold hospices accountable for harming beneficiaries.
What are the rights of hospice beneficiaries?
Medicare hospice beneficiaries have the right to be free from abuse, neglect, and other harm. When hospices cause harm or fail to take action when harm is caused by others, beneficiaries are deprived of these basic rights. This report is the second in a two-part series addressing hospice quality of care.
How much did Medicare spend on hospice care?
The number of hospice beneficiaries has grown every year for the past decade. In 2017, Medicare spent $17.8 billion for hospice care for nearly 1.5 million beneficiaries, up from $9.2 billion for less than 1 million beneficiaries in 2006.
How does CMS protect hospices?
To effectively protect beneficiaries from harm, CMS must have enforcement tools . In addition, we make several new recommendations to strengthen safeguards to protect Medicare hospice beneficiaries from harm: CMS should (1) strengthen requirements for hospices to report abuse, neglect, and other harm; (2) ensure that hospices are educating their staff to recognize signs of abuse, neglect, and other harm; (3) strengthen guidance for surveyors to report crimes to local law enforcement; (4) monitor surveyors’ use of immediate jeopardy citations; and (5) improve and make user-friendly the process for beneficiaries and caregivers to make complaints. CMS concurred with the first four of these recommendations and partially concurred with the fifth.
How often do hospices need to be surveyed?
The Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) established the requirement that Medicare hospices must be surveyed at least every 3 years. Prior to this Act, neither law nor regulation specified the frequency of Medicare surveys for hospices. See also, 42 CFR § 488.5(a)(4)(i).
How is hospice paid?
1042 CFR § 418.302. For continuous home care, the hospice is paid an hourly rate based on the number of hours of continuous care furnished to the beneficiary on that day. CMS,
What does CMS do with complaints?
CMS tracks these complaints, categorizing them into different severity levels to determine which actions to take.16For more severe complaints, CMS requires the State agency to conduct onsite surveys to investigate within certain timeframes.
WHY WE DID THIS REVIEW
Opioid-related overdose deaths in the United States are at an all-time high, reaching an estimated 70,000 deaths in 2020. As the country continues to struggle with the opioid crisis, it is critical that people who are suffering from opioid use disorder have access to treatment.
HOW WE DID THIS STUDY
We analyzed claims from Medicare Parts B, C, and D to determine the extent to which beneficiaries diagnosed with opioid use disorder received medication and behavioral therapy to treat their opioid use disorder through Medicare in 2020.
WHAT WE FOUND
About 1 million Medicare beneficiaries were diagnosed with opioid use disorder in 2020. Yet less than 16 percent of these beneficiaries received medication to treat their opioid use disorder, raising concerns that beneficiaries face challenges accessing treatment.
WHAT WE RECOMMEND
These findings show a need to increase the number of Medicare beneficiaries receiving treatment for opioid use disorder.
WHY WE DID THIS STUDY
In response to the COVID-19 pandemic, both Congress and the Department of Health & Human Services (HHS) expanded access to a wide range of medical services that can be delivered via telehealth (i.e., telehealth services).
HOW WE DID THIS STUDY
We reviewed Medicare claims data for telehealth services provided from March through December 2020.
WHAT WE FOUND
Most beneficiaries received telehealth services from providers with whom they had an established relationship. Notably, 84 percent of beneficiaries received telehealth services only from providers with whom they had an established relationship.
WHAT WE CONCLUDE
Data on how likely beneficiaries are to receive telehealth services from a provider with whom they have had an established relationship can be used to inform decisions about how to best use telehealth in Medicare and should be taken into account as policymakers continue to examine telehealth utilization and concerns about telehealth being vulnerable to fraud, waste, and abuse.