Medicare Contractor's Payments in Jurisdiction 6 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. 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. 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. Noridian Administrative Services became the fiscal intermediary for the State of Minnesota in August 1999. On September 30, 2011, CMS awarded the Medicare Administrative Contractor contract for Jurisdiction 6, which includes Minnesota, to National Government Services; however, protests were filed against the award. In the meantime, Noridian Administrative Services, acting as the legacy fiscal intermediary, continues to process claims for providers in Minnesota. During our audit period (January 1, 2008, through December 31, 2010), 3,634 line items for Herceptin totaling approximately $6.5 million were processed in Minnesota. Of these 3,634 line items, 464 totaling approximately $1.3 million had unit counts with multiples of 44 (44, 88, 132, etc.) 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 Noridian Administrative Services made to providers for full vials of Herceptin were correct.