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Audit (A-07-11-04181)

12-12-2012
Providers Did Not Correctly Bill Medicare Part B for the Oral Form of the Drug Emend

Executive Summary

In general, the five selected providers that we reviewed did not correctly bill Medicare Part B for the oral form of Emend (the brand name of aprepitant, which is one of three drugs in a regimen of oral anti-emetic drugs that are prescribed to help reduce nausea and vomiting in chemotherapy patients). Our audit found that 1,912 of 2,105 selected line items for the oral form of Emend for outpatient services paid under Medicare Part B during calendar year 2010 were incorrect. The 1,912 incorrect line items included overpayments totaling $531,000 made to 5 selected providers because not all of the required drugs in the regimen were included on the same claim. During our fieldwork, the five selected providers informed us that they had returned the overpayments. The remaining 193 line items were correct.

The Balanced Budget Act of 1997 provided coverage under Medicare Part B for oral anti-emetic drugs administered or prescribed under a chemotherapeutic regimen. Centers for Medicare & Medicaid Services (CMS) guidance states that, for the oral form of Emend to be payable as an outpatient service under Medicare Part B, providers must administer or prescribe a three-drug oral regimen (consisting of Emend, a 5-HT3 antagonist, and dexamethasone), along with at least one of nine specified anticancer chemotherapeutic agents. In addition, CMS guidance states that all three drugs in the oral regimen, as well as the qualifying anticancer chemotherapeutic agent, should be billed on the same claim for Emend to be allowable for payment under Medicare Part B.

We recommended that CMS (1) verify that the $531,000 in identified overpayments made to the five selected providers has been refunded to the Federal Government; (2) direct the five selected providers to review the remaining CY 2010 line items on claims for the oral form of Emend that were not reviewed as part of this audit, as well as all subsequent claims, and refund any overpayments; (3) develop and implement system edits to prevent payments for the oral form of Emend when providers do not bill for all of the required drugs in the regimen on the same claim; and (4) use the results of this audit to educate providers. CMS concurred with three of our four recommendations. CMS did not concur with our third recommendation and stated that it would investigate the issue and provide an update on its planned course of action at a later date.

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