
Specialty Drugs
Medicaid spending on specialty drugs has rapidly increased. There is no standard definition for specialty drugs. They may be expensive; be difficult to handle, monitor or administer; or treat rare, complex or chronic conditions. The OIG will describe States' definitions of, and payment methodologies for, Medicaid specialty drugs and determine how much States paid for specialty drugs. The OIG will also review strategies that States use to manage specialty drug costs, such as formularies, cost sharing, step therapy, and prior authorization.Bariatric Surgeries
Bariatric surgery is performed to treat comorbid conditions associated with morbid obesity. Medicare Parts A and B cover certain bariatric procedures if the beneficiary has (1) a body mass index of 35 or higher, (2) at least one co-morbidity related to obesity, and (3) been previously unsuccessful with medical treatment for obesity (CMS, Medicare National Coverage Determinations Manual, Pub. No. 100-03, chapter 1, part 2, § 100.1). Treatments for obesity alone are not covered. The Comprehensive Error Rate Testing program's special study of certain Healthcare Common Procedure Coding System codes for bariatric surgical procedures found that approximately 98 percent of improper payments lacked sufficient documentation to support the procedures (CMS, Medicare Quarterly Provider Compliance Newsletter, "Guidance to Address Billing Errors," volume 4, issue 4, July 2014). The OIG will review supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with Federal requirements (Social Security Act, §§ 1815(a) and 1833(e)).Telehealth Services
Medicare Part B covers expenses for telehealth services on the telehealth list when those services are delivered via an interactive telecommunications system, provided certain conditions are met (42 CFR § 410.78(b)). To support rural access to care, Medicare pays for telehealth services provided through live, interactive videoconferencing between a beneficiary located at a rural originating site and a practitioner located at a distant site. An eligible originating site must be the practitioner's office or a specified medical facility, not a beneficiary's home or office. The OIG will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.Comparison of Provider-Based and Freestanding Clinics
Provider-based facilities often receive higher payments for services than freestanding clinics. The OIG will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to the clinics for similar procedures. They will also assess the potential impact on Medicare and beneficiaries of hospitals' claiming provider-based status for such facilities.Medicare Part D Rebates Related to drugs Dispense by 340B Pharmacies
Drug manufacturer rebates reduce the cost of the Part D program to beneficiaries and the Government. Manufacturers frequently do not pay rebates for Part D prescriptions filled at 340B covered entities and contract pharmacies since they are already providing a discount on the purchase of the drug. The Medicare Part D program does not share in the purchase discounts. Savings could be realized if requirements similar to those of the Medicaid Drug Rebate Program that require manufacturers to pay rebates were adopted by the Medicare Part D program. The OIG will determine the upper bound of what could be saved if pharmaceutical manufacturers paid rebates for drugs dispensed through the Medicare Part D program at 340B covered entities and contract pharmacies. The OIG Work Plan can be found at the following website location:
- Responsibility, Arranger, Includer, Harmony, Communication
Kirk Delperdang
Kirk Delperdang, Healthcare Director, began his career in 1993. With extensive experience in Medicare auditing and reimbursement management, he brings valuable regulatory insight to his role at Lutz.
Specializing in Medicare services for healthcare facilities, Kirk provides comprehensive guidance on enrollment, cost reporting, reimbursement analyses, and compliance matters. He focuses on delivering expert solutions to help community hospitals navigate complex Medicare requirements. Kirk values the opportunity to support healthcare organizations with the specialized knowledge they need to succeed.
At Lutz, Kirk's strong sense of responsibility and talent for arranging complex processes makes him an invaluable resource for clients. His methodical approach to Medicare compliance, combined with his clear communication style, helps facilities maintain proper enrollment while optimizing their reimbursement strategies.
Kirk lives in Omaha, NE, with his wife, Leslie. Outside the office, he enjoys spending time outdoors and with family.
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