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Audit (A-03-11-00014)

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

Executive Summary

Most payments for one or more full vials of Herceptin that the Medicare contractors made to providers in four of the five States in Jurisdiction 12 (Delaware, the District of Columbia, New Jersey, and Pennsylvania) from January 2008 through December 2010 were incorrect. Herceptin (trastuzumab) is a Medicare-covered biological drug used to treat breast cancer that has spread to other parts of the body.

Of the 1,454 selected line items, 1,165 were incorrect and included overpayments totaling $1.6 million that the providers had not identified or refunded by the beginning of our audit. Providers refunded overpayments on three line items totaling $6,600 before our fieldwork. The remaining 286 line items were correct.

The 1,165 incorrect line items included incorrect units of service and a lack of supporting documentation. The providers attributed the incorrect payments to chargemaster errors, clerical errors, and billing systems that could not prevent or detect the incorrect billing of units of service. In some cases, providers could not store unused doses for later use because their pharmacies incorrectly reconstituted the Herceptin. When this occurred, the providers billed Medicare for the entire vial, including waste. The Medicare contractors made these incorrect payments because neither the Fiscal Intermediary Standard System nor the Common Working File had sufficient edits in place during our audit period to prevent or detect the overpayments.

We recommended that Novitas Solutions, Inc., the current Medicare Administrative Contractor for Jurisdiction 12: (1) recover the $1.6 million in identified overpayments, (2) implement a system edit that identifies for review line items for multiuse-vial drugs with units of service equivalent to one or more entire vials, and (3) use the results of this audit in its provider education activities. Novitas concurred with our findings and recommendations and described corrective actions that it had taken or planned to take.

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