1. Medicare Payment for Irinotecan (OEI-03-08-00310)
2. Review of High-Dollar Payments for Rhode Island Medicare Outpatient
3. Review of Blue Cross and Blue Shield of Georgia Medicare Payments to Providers Terminated From January 1, 2003, Through January 31, 2007 (A-05-08-00039)
4. Medical Review of Claims for the Fiscal Year 2006 Comprehensive Error Rate Testing Program (A-01-07-00508)
5. Follow-Up Audit of the Medicaid Drug Rebate Program in Vermont (A-01-08-00004)
6. Review of Medicaid Overpayments at North Country Associates, Inc., in Maine for Calendar Years 2004 Through 2006 (A-01-07-00012)
7. Comparison of Fourth-Quarter 2007 Average Sales Prices and Average Manufacturer Prices:  Impact on Medicare Reimbursement for Second-Quarter 2008  (OEI-03-08-00340)
8. Review of Inpatient Hospital Claims Billed as Family Planning Under New Jersey’s Medicaid Program (A-02-06-01020)
9. Review of High-Dollar Payments for Maryland Medicare Part B Claims Processed by TrailBlazer Health Enterprises for the Period January 1, 2003 Through December 31, 2005
(A-03-07-00017)

1. Medicare Payment for Irinotecan (OEI-03-08-00310) http://www.oig.hhs.gov/oei/reports/oei-03-08-00310.pdf

Irinotecan hydrochloride (hereinafter referred to as irinotecan) is an injectable drug used to treat patients with colorectal cancer.  The Food and Drug Administration approved the first generic version of irinotecan on February 20, 2008.  This study examines the difference between the Medicare payment amount and manufacturer-reported sales prices during March 2008.  At that time, generic versions of irinotecan were available for purchase, but not yet factored into the calculation of the Medicare payment amount because of the two-quarter lag in the payment system. 

The OIG found that the Medicare payment amount for irinotecan ($126.31) was more than double the OIG-calculated average manufacturer sales price ($51.59).  In addition, had the Medicare payment amount for irinotecan been based on the average manufacturer sales price in March 2008, Medicare and its beneficiaries would have saved an estimated $6.5 million in that month alone.  The OIG recommends that CMS explore options to expedite the process to ensure that the Medicare payment amounts for drugs with newly available generic versions accurately reflect market prices.  CMS concurred with the OIG's  recommendation. 

 

2. Review of High-Dollar Payments for Rhode Island Medicare Outpatient Claims Processed by Pinnacle Business Solutions, Inc., for Calendar Years 2004 Through 2006 (A-01-08-00512) http://www.oig.hhs.gov/oas/reports/region1/10800512.pdf

During calendar years 2004-2006, Pinnacle Business Solutions, Inc., overpaid providers in Rhode Island $141,000 for high-dollar (greater than $50,000) Medicare outpatient claims.

 

3. Review of Blue Cross and Blue Shield of Georgia Medicare Payments to Providers Terminated From January 1, 2003, Through January 31, 2007 (A-05-08-00039) http://www.oig.hhs.gov/oas/reports/region5/50800039.pdf

Blue Cross and Blue Shield of Georgia, Inc., a Medicare fiscal intermediary, made unallowable Medicare payments totaling $14,000 to two providers for services that were performed after the providers were terminated from Medicare.

4. Medical Review of Claims for the Fiscal Year 2006 Comprehensive Error Rate Testing Program (A-01-07-00508) http://www.oig.hhs.gov/oas/reports/region1/10700508.pdf

In two reviews of beneficiaries’ medical records, KePRO, an independent medical review contractor, identified errors in claims for durable medical equipment, prosthetics, orthotics, and supplies (DME) that the Comprehensive Error Rate Testing (CERT) contractor had not identified.  The Centers for Medicare and Medicaid Services (CMS) used the results of the CERT contractor’s medical review to produce a DME paid claim error rate for fiscal year (FY) 2006.  

KePRO’s first review, which used the same procedures and limited medical records that the CERT contractor used, found that the CERT contractor’s review was adequate for 324 of the 363 sampled claims, including 23 claims that both the CERT contractor and KePRO determined to be erroneous.  However, KePRO identified 39 errors that the CERT contractor had not identified.  Based on the 23 errors that both contractors found and the additional 39 errors that KePRO found, the OIG estimated that the error rate in the FY 2006 CERT DME sample was 17.3 percent.  KePRO’s second review, using additional medical records from physicians and other health care providers and, in some cases, information obtained from beneficiary and provider interviews, confirmed 20 of the 23 errors that the CERT contractor had found and identified 73 errors that the CERT contractor had not found.  Specifically, KePRO confirmed 34 of the 39 errors identified in its initial review and determined that another 39 claims were erroneous.  Based on the 20 errors that both contractors found and the additional 73 errors that KePRO found, the OIG estimated that the error rate in the FY 2006 CERT DME sample was 28.9 percent.

The OIG recommended that CMS (1) require the CERT contractor to review all available supplier documentation, (2) establish a written policy to address the appropriate use of clinical inference, (3) require the CERT contractor to review all medical records necessary to determine compliance with applicable requirements on medical necessity, (4) document oral guidance that conflicts with written policies, (5) instruct its Medicare contractors to provide additional training to physicians on improving their medical record documentation, and (6) require the CERT contractor to contact the beneficiaries named on high-risk claims to help determine whether the beneficiaries received the items and the items were medically necessary.  CMS generally agreed with the OIG's findings and recommendations.

5. Follow-Up Audit of the Medicaid Drug Rebate Program in Vermont (A-01-08-00004) http://www.oig.hhs.gov/oas/reports/region1/10800004.pdf

The Agency of Human Services, Office of Vermont Health Access (the State agency) had not implemented the recommendations from the OIG's  prior audit of the Medicaid drug rebate program in Vermont.  The State agency also did not have adequate policies and procedures for reconciling and reporting its pending drug rebate amounts on Form CMS 64.9R to ensure the accuracy of pending drug rebate amounts reported to the Centers for Medicare and Medicaid Services.  The State agency had established controls over collecting rebates on single-source drugs administered by physicians.

6. Review of Medicaid Overpayments at North Country Associates, Inc., in Maine for Calendar Years 2004 Through 2006 (A-01-07-00012) http://www.oig.hhs.gov/oas/reports/region1/10700012.pdf

The Maine Department of Health and Human Services (the State agency) made overpayments totaling $618,000 ($400,000 Federal share) because the State agency did not adjust its Medicaid per diem payments to North Country Associates, Inc., by the amount of beneficiaries’ cost-of-care contribution from other resources, such as Social Security and pensions. 

7. Comparison of Fourth-Quarter 2007 Average Sales Prices and Average Manufacturer Prices:  Impact on Medicare Reimbursement for Second-Quarter 2008  (OEI-03-08-00340) http://www.oig.hhs.gov/oei/reports/oei-03-08-00340.pdf

Pursuant to section 1847A(d)(3) of the Social Security Act (the Act), OIG must notify the Secretary of the Department of Health and Human Services (the Secretary) if the average sales price (ASP) for a particular drug exceeds the drug’s average manufacturer price (AMP) by a threshold of 5 percent.  If that threshold is met, section 1847A(d)(3) of the Act grants the Secretary authority to disregard the ASP for that drug and substitute the payment amount for the drug code with the lesser of the widely available market price for the drug (if any) or 103 percent of the AMP. 

This review is the seventh such comparison conducted by OIG; however, it is OIG’s first pricing comparison since CMS implemented a revised ASP payment methodology recently mandated by section 112(a) of the Medicare, Medicaid, and SCHIP Extension Act of 2007, P.L. 110-173.  Using CMS’s revised ASP payment methodology, the OIG identified 12 of 285 drug codes with ASPs that exceeded AMPs by at least 5 percent in the fourth quarter of 2007. 

If reimbursement amounts for all 12 codes had been based on 103 percent of AMP, the OIG estimate that Medicare expenditures would have been reduced by $20 million during the second quarter of 2008 alone. 

 

8. Review of Inpatient Hospital Claims Billed as Family Planning Under New Jersey’s Medicaid Program (A-02-06-01020) http://www.oig.hhs.gov/oas/reports/region2/20601020.pdf

New Jersey improperly received Federal Medicaid reimbursement for family planning claims because the State’s electronic Medicaid claims system did not identify all claims for which a family planning service was performed with a non-family-planning procedure during a single inpatient hospital stay and because some hospitals did not properly complete sterilization consent forms.  As a result, the State improperly received $163,000 in Federal Medicaid funds.

9. Review of High-Dollar Payments for Maryland Medicare Part B Claims Processed by TrailBlazer Health Enterprises for the Period January 1, 2003 Through December 31, 2005
(A-03-07-00017) http://www.oig.hhs.gov/oas/reports/region3/30700017.pdf

TrailBlazer Health Enterprises (TrailBlazer) overpaid providers $145,000 for 15 of the 49 high-dollar payments ($10,000 or more) the OIG reviewed in detail for calendar years 2003-05. Thirty-four payments were appropriate. A copy of the final report was provided to the Medicare contractor for final resolution of the two outstanding overpayments totaling $18,000).