Medicare Contractor's Payments to Providers in Four States in Jurisdiction 12 for Full Vials of Herceptin Were Often Incorrect.

摘要

Herceptin (trastuzumab) is a Medicare-covered biological drug used to treat breast cancer that has spread to other parts of the body. Herceptin comes in a multiuse vial containing 440 milligrams. A multiuse vial contains more than one dose of medication and is labeled as such by the manufacturer. A vial of Herceptin reconstituted with bacteriostatic water is stable for 28 days when stored properly. An entire multiuse vial of Herceptin represents 44 units for billing Medicare. However, for multiuse vials, Medicare pays only for the amount administered to a beneficiary and does not pay for any discarded amounts of the drug. Therefore, a payment for an entire multiuse vial is likely to be incorrect. This audit is part of a nationwide review of the drug Herceptin. The pilot of these reviews found that the Medicare contractors payments for full vials of Herceptin were often incorrect. Title XVIII of the Social Security Act established the Medicare program to provide health insurance for people aged 65 and over and individuals with disabilities or permanent kidney disease. Part B of the Medicare program provides supplementary medical insurance for medical and other health services, including outpatient services such as the injection of drugs. The Centers for Medicare & Medicaid Services (CMS), which administers the program, contracts with Medicare contractors to process and pay Medicare claims submitted for outpatient services. The Medicare contractors use the Fiscal Intermediary Standard System and CMSs Common Working File (CWF) to process claims. The CWF can detect certain improper payments during prepayment validation. Providers should use the appropriate Healthcare Common Procedure Coding System (HCPCS) code for the drug administered and report units of service in multiples of the units shown in the HCPCS narrative description. This report includes the results for providers in four of the five States in Jurisdiction 12 (Delaware, the District of Columbia, New Jersey, and Pennsylvania).