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OIG: Chemo Admin Claims Slip Through System

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  • In CMS
  • July 2, 2009
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The Office of Inspector General (OIG) is recommending the Centers for Medicare & Medicaid Services (CMS) do more to ensure Medicare Part B claims for chemotherapy administration services are appropriate.

This recommendation was prompted after the OIG was unable to determine whether Medicare appropriately paid for Part B services billed as chemotherapy administration from 2005 to 2007 because of “insufficient” data.

The OIG found in its analysis that Medicare allowed $17.1 million for chemotherapy administration claims on days that no drug was billed and $43.5 million for chemotherapy administration claims on days that only nonqualifying drugs were billed. The OIG was unable, however, to determine definitively whether these unmatched claims were truly inappropriate because they could not rule out the possibility that providers administered qualifying drugs but did not bill Medicare for them.

The problem, the OIG inferred, is twofold. First, there isn’t a national definition of “qualifying drug.” Second, there isn’t a way to track unmatched chemotherapy administration claims.

“Specifically, Part B data do not identify drugs that are not billed to the program even when their administration is billed to Part B,” the OIG says in its report.

To remedy the situation, the OIG recommends CMS:

  1. Establish a process to determine which specific drugs qualify for the chemotherapy administration payment rate;
  2. Instruct carriers that have not conducted a probe review of unmatched chemotherapy administration claims to do so; and
  3. Ensure drug administration claims are coded correctly and paid appropriately.

CMS said it agreed carriers should conduct probe reviews, but it did not agree with the other two recommendations.

Current CPT® guidance, CMS replied, “represents the best consensus from the medical community and CMS regarding the appropriate CPT codes for reporting the administration of different types of drugs.” And, continued CMS, the cost for developing a special system, such as the one allowing the submission of “no pay” claims for the Competitive Acquisition Program (CAP) for Part B drugs and biologicals, would outweigh the benefit.

You can read the full report, “Medicare Part B Chemotherapy Administration: Payment and Policy,” on OIG’s Web site.

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