Review of Medicare Outpatient Billing for Selected Drugs at Central Peninsula General Hospital

摘要

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. Medicare guidance requires providers to submit accurate claims for outpatient services. Each submitted Medicare claim contains detail regarding each provided service (called a line item in this report). Providers should use the appropriate Healthcare Common Procedure Coding System (HCPCS) codes and report units of service as the number of times that a service or procedure was performed or, if the HCPCS code is associated with a drug, the number of units administered. Medicare requires providers to bill one service unit for each 10-milligram injection of doxorubicin HCl liposome and one service unit for each 30-milligram injection of paclitaxel. Central Peninsula General Hospital (Central Peninsula) is a 49-bed, not-for-profit acute-care community hospital located in Soldotna, Alaska. Based on data analysis, we reviewed 25 line items that Central Peninsula billed to Medicare during our audit period (April 1, 2008, through February 28, 2011): 3 line items for doxorubicin HCl liposome injections and 22 line items for paclitaxel injections. Our objective was to determine whether Central Peninsula billed Medicare for doxorubicin HCl liposome and paclitaxel injections in accordance with Federal requirements.