Warning: Opdivo is New RAC Target

By
Original story posted on: October 7, 2020

Opdivo is an immunotherapy treatment for advanced cancer.

What is Opdivo? It’s a new target for Recovery Audit Contractors (RACs), specifically Performant Recovery. Opdivo is an immunotherapy treatment for advanced cancer or cancers that have been resistant to other treatments. While this is a newer drug, Medicare will still cover the cost of cancer treatment with Opdivo.

  • Medicare covers cancer treatment under parts A, B, and C, depending on which phase of treatment you’re in, where you receive treatment, and the plan you have.
  • Medicare pays for Opdivo as an outpatient infusion: the consumer will pay a 20-percent copayment for each infusion after the Part B deductible has been met.

Opdivo is fairly new, having been approved by the Food and Drug Administration (FDA) in 2015. Despite this, cancer treatments are covered under original Medicare. Original Medicare is made up of two main parts: Part A and Part B. J9299 is a valid 2020 HCPCS code for Injection, nivolumab, 1 mg or just “Injection, nivolumab” for short, used in medical care J9299 has been in effect since Jan. 1, 2016.

The reason that I think Opdivo will be one of the upcoming RAC audit targets is because the dollar amount is high, per injection. If an auditor finds no medical necessity or a documentation error for even just 10 dates of service, we are already talking about high costs. Then add in an extrapolation here and there.

The cost of Opdivo depends on the dosage you receive and how long you receive treatment. Opdivo is considered a specialty medication in both its brand name and generic forms.

Depending on the dose, Opdivo can cost $6,580 per infusion.

Performant Recovery Inc., which is covering New York, Maine, New Hampshire, Massachusetts, Rhode Island, Connecticut, Ohio, Kentucky, Indiana, and Michigan, has been instructed by CMS to review and audit for drugs and biologicals with excessive use, or insufficient drug units billed. Performant is also in Region 5 – the national U.S. contract for durable medical equipment (DME) and home health and hospice (HHH).

Opdivo should be billed in multiples of the dosage specified in the HCPCS code long descriptor.

The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor and should correspond to the actual amount of the drug administered to the patient, including any appropriate discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, registered pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units.

If you do not, beware of upcoming audits. Self-audit. Self-report.

Programming Note: Knicole Emanuel, Esq. is a permanent panelist on Monitor Mondays. Listen to her RAC Report every Monday at 10 a.m. EST.

Knicole C. Emanuel Esq.

For more than 20 years, Knicole has maintained a health care litigation practice, concentrating on Medicare and Medicaid litigation, health care regulatory compliance, administrative law and regulatory law. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards.  She has successfully obtained federal injunctions in numerous states, which allowed health care providers to remain in business despite the state or federal laws allegations of health care fraud, abhorrent billings, and data mining.  Across the country, Knicole frequently lectures on health care law, the impact of the Affordable Care Act and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals and durable medical equipment providers. Knicole is partner at Practus, LLP and a member of the RACmonitor editorial board and a popular panelist on Monitor Monday.

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

Related Articles

  • Medicare Auditors Fail to Follow the Jimmo Settlement
    Some Uniform Program Integrity Contractors (UPICs) have failed to follow the Jimmo settlement standard. Auditors are not lawyers. Some auditors do not even possess the clinical background of the services they are auditing. I’m concentrating on the lack of legal…
  • The Death of the IPO is not the Death of Medical Necessity: Part II
    The decision to admit to inpatient or to place in observation is a medical necessity matter. On the American Case Management Association (ACMA) Learning Link, a member recently posed this question: “Does your institution use outpatient in a bed status…
  • Rebilling Non-Medicare Inpatient Claims – Is it Observation or Not? 
    It is crucial to understand the differentiation between a denial for lack of medical necessity and a denial for incorrect status. Last week marked the eighth anniversary of the Centers for Medicare & Medicaid Services (CMS) release of ruling CMS-1455-R.…