August 14, 2012

Herceptin Billing on OIG, RACs Radar

By

alert-powered-by-decision-health

A pair of HHS Office of Inspector General (OIG) reports shows incorrect payments for Herceptin (trastuzumab), a breast cancer drug, in two Medicare jurisdictions.

In Jurisdiction 12, payments for one or more full vials of Herceptin from January 2008 to December 2010 were incorrect in 80% of the 1,454 line items, according to a July 31 OIG report. That totaled $1.6 million in overpayments in Delaware, New Jersey, Pennsylvania and Washington, D.C.

The incorrect line items included “incorrect units of service and lack of supporting documentation,” the report summary stated. Providers had several reasons for the incorrect payments, including that they “could not store unused doses for later because their pharmacies incorrectly reconstituted the Herceptin,” the reported summary stated. That resulted in providers billing Medicare for the entire vial including waste.

According to a July 27 report, OIG found Noridian Administrative Services in Jurisdiction 6 made incorrect payments totaling $557,000 for 79% of 464 line items. Providers reported the units of service for the entire vial instead of what was administered, the report stated. “The providers attributed the incorrect payments to clerical errors and to billing systems that could not prevent or detect the incorrect billing of units of service,” the report summary stated.

Providers likely have been aware of challenges billing Herceptin. Two of the recovery auditors (RACs) – Region C RAC Connolly and Region D RAC HealthDataInsights – have posted Herceptin issues.

For more on those reports, visit the following OIG websites: http://oig.hhs.gov/oas/reports/region3/31100014.asp and http://oig.hhs.gov/oas/reports/region5/51200010.asp.

RAC News

RAC Region A posted six issues for various states in its jurisdiction. The issues are for ambulatory surgical centers, DME suppliers, laboratories, and physicians and non-physician practitioners. See the chart below for more details.

 

Ambulatory surgical center

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Diagnostic colonoscopy, sigmoidoscopy and proctosignoido-scopy not supported by medical necessity (NGS LCD L26404 [A45926])

8/6/12

Conn., N.Y.

Diagnostic colonoscopy, sigmoidoscopy and proctosigmoidoscopy - potential incorrect billing occurred for claims billed with ICD-9-CM codes that are not listed by National Government Services (NGS) local coverage determination (LCD) L26404 (A45926) as medically necessary.

Social Security Act sections 1862(a)(1)(A), 1833(e); NGS LCD L26404; NGS article A45926; CMS Pub. 100-04 chapter 12; CFR 42 section 410.329(a)

 

DME supplier

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Group 2 pressure-reducing support surfaces

8/6/12

RAC Region A

Group 2 pressure-reducing support surface claims that do not meet the indications of coverage and/or medical necessity related to LCD L5068 (A35350).

NHIC LCD L5068; CMS Pub. 100-03 chapter 1; CMS Pub. 100-02 chapter 15; CMS Pub. 100-08 chapter 5; OIG report OEI-02-07-00420; CMS Pub. 100-04 chapter 30; DME Coding System, DME pricing data analysis coding – support surfaces

 


 

Laboratory

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Hepatic function panel testing

8/6/12

Conn., N.Y.

Potential incorrect billing occurred for claims billed with ICD-9-CM codes that are not listed by National Government Services (NGS) local coverage determination (LCD) L27377 (A47395) as medically necessary.

Social Security Act sections 1862(a)(1)(A), 1833(e); NGS LCD L27377; NGS article A47395; CMS Pub. 100-04 chapter 16

 

Physician/non-physician practitioner

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Hepatic function panel testing

8/6/12

Conn., N.Y.

Hepatic function panel: Potential incorrect billing occurred for claims billed with ICD-9-CM codes that are not listed by National Government Services (NGS) local coverage determination (LCD) L27377 (A47395) as medically necessary.

Social Security Act sections 1862(a)(1)(A), 1833(e); NGS LCD L27377; NGS article A47395; CMS Pub. 100-04 chapter 16

Diagnostic colonoscopy, sigmoidoscopy and proctosignoido-scopy not supported by medical necessity

8/6/12

Conn., N.Y.

Diagnostic colonoscopy, sigmoidoscopy and proctosigmoidoscopy - potential incorrect billing occurred for claims billed with ICD-9-CM codes that are not listed by National Government Services (NGS) local coverage determination (LCD) L26404 (A45926) as medically necessary.

Social Security Act sections 1862(a)(1)(A), 1833(e); NGS LCD L26404; NGS article A45926; CMS Pub. 100-04 chapter 12; CFR 42 Section 410.329(a)

Electrocardiography (EKG)

8/6/12

Conn., D.C., Del., Md., N.J., N.Y., Pa.

Potential incorrect billing of services not supported by medical necessity

Social Security Act sections 1862(a)(1)(A), 1833(e); Medicare National Coverage Determination Manual chapter 1; NGS LCD L27427; NGS article A47417; Novitas LCD L27490

About the Authors

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement. Tina Irgang is the editor of Home Health and Hospital Solutions for DecisionHealth.

Contact the Authors

KLong@decisionhealth.com

tirgang@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

Karen Long

This email address is being protected from spambots. You need JavaScript enabled to view it.