Medicare Contractor's Payments in Jurisdictions 6, 8, and 15 to Providers for Full Vials of Herceptin Were Often Incorrect.

摘要

Herceptin, also known as trastuzumab, is a Medicare-covered drug used to treat breast cancer that has spread to other parts of the body. Herceptin comes in a multiuse vial of 440 milligrams. A multiuse vial contains more than one dose of medication and is labeled as such by the manufacturer. The manufacturer supplies the drug in a carton containing a multiuse vial of 440 milligrams of Herceptin and one 20-milliliter vial of bacteriostatic water for injection (BWFI) containing a solution of 1.1 percent benzyl alcohol as a preservative. A vial of Herceptin, when reconstituted with BWFI and stored properly, can be used for up to 28 days. For multiuse vials, Medicare pays only for the amount administered to a beneficiary and does not pay for any discarded drug. Therefore, a payment for an entire multiuse vial is likely to be incorrect. Previous Office of Inspector General reviews have noted that providers may not be billing Herceptin lines of service correctly. Pursuant to Title XVIII of the Social Security Act, the Medicare program provides health insurance for people aged 65 and over and those who are disabled or have permanent kidney disease. The Centers for Medicare & Medicaid Services administers the program. Effective January 1, 2007, National Government Services became the Medicare contractor in Illinois, Indiana, Michigan, Ohio, and Wisconsin. During our audit period (January 1, 2007, through December 31, 2009), 23,085 line items for Herceptin totaling approximately $38.7 million were processed in these States. Of these 23,085 line items, 3,966 totaling approximately $9.6 million had 44, 88, 132, or 176 units of service that represent billings equivalent to entire multiuse vials. In this audit, we did not review entire claims; rather, we reviewed the specific line items within the claims that met these criteria. Our objective was to determine whether Medicare payments that National Government Services made to providers for full vials of Herceptin were correct.