U~TEB SMES GENERAL Accou~mNc OFFICE WASHINGTON, I3 C 20548 TzitLb XV;r$f of tkm So&d. Seemrity Act protides, in pat, that Hedicwe coverage of Capugsand biologkals s&U include: Initial instmctiona 3ssued by SSA in Ju3.y 1966 provided that dmgs and biologhals wwe covered only if thy wema of the type that, could not be self-admmstimd by injection, Vaceinatio~ OP imocu%ations W&~FBcovwad if tkay wem dizwtly related to tmat- merit of an iqpry OF direct exposure such as antirabies treatment, P19tamus, 2mtitoanhra, etc, SSA instmcted its regional offices in April. 1968 that the detimmat~on of tiethm the dmgs OF biologicah are of the type S0Tl-l ANNIVERSARY 1921-1971 w&.&h can be salf-adrdnis~~~d should be based on the usual. method --..s- of adzn%niatration Father Ihan on the fox% ia which th&mf&t be given in an ind%vj.dua.l. case. Althoug~ugs and bfologicaT6.s wh?Lch ccmld be self-adminiete~ed were excluded frpom EedicaaJe covepage, the instruction p%otided -&.a% ckx~ges for concurx?ent sar~vices tiich the beneficiary recef~d, such as the adminis%Wxon of the in~ectim, could be coveleed, F$z3cause som0 carriers ware having dlfficufti03 in implenenting the April n968 fmtFzrctions, SSA ncevzsed its iust~uctions in April 1969. !the retised intst~uctions cha~~ged the csfxte~xa and pyovxded that the detepmiaat%on of whether a drug OII’ biologic&L is of a type wfhich cannot ba self-admitistered would bs based oyll the usual method sf ack&=daQ~atxon sf f&a fom of Umt dmg OP biologkeal. as fkrnished by the indzvxdual physicGxn. En othea4 wopds, &en a phy~&~~an 3njects a drug which is not uaurdbby self-injected, the injectkon charge would be covered (reg~d3ess of whethu~ the &ug may also be avaalable 1~1 oval form) because it was not self- administered in the form actually furnished to the patfent, Under the Aprtl I.969 instructions J the primary emphasis as to whethe drugs and biologi4.s were covezed serv%ces was placed on a detex!mination of wheule~; these se~ticea were %(easonabEa and necessary for the treatment of the il3..z1ess ox” anjury for which they tmm aakRWs&sPed. The LnstFuctions stated that cax9ien(s should develop guxdeki.nes to screen ou> injectzLon. chaFges that did not meet the afopementioad cx%.teria. The carriers* problems in admini&eriu,g Nedicae pro~&ions 8(elattig to &ugs and biologkxls fi??st cme to out attention in fiscal year 1969 dur%ng OUF sletiew of pnaoceduras used by the carriers to dete9’mLne the reasonableness of physieians~ chages. As pax% of that review, we ezxmined a Ipandom sample of 100 claims processed by each camie~ and noted that --aILl six CarFAeFS wer0 allowing Ch2P@S for vitamin injections &ich, according to the April I.968 inst~uctfons, should have been disallowed because the usual method of admfn~a~ring these &ugs was by tablet OF other self- administerable oral form, -4I.l. six carriers were allo%Jmg charges for unidentified injections without detesmiting whether the injections were of the type coveFed by Hedicae, and --two of the caFrxepIs were allowing chaPges for immunfeations which were not coveyed by the program. -2- ‘Ijajactions hjections hjectrions considex!ed considered Imjectio%as allowed by disallowable questionable claimed lxaF%l%x1S No, Amoumt Aetna- oE%$Onr Ctif02tia 161 129 $56183 $332 7 $ 32 Blue 23hield 65 54 254 20 89 9 45 FlOFida Blugr Sh.5el.d 111 103 394 38 150 28 99 l4%tiago1ita.m- New Hozk 9s 93 339 55 257 7 l-9 Pan‘-AmePican- %OU%Siajwa 103 97 351 24 84 12 60 Texas Blue Shield 139 135 726 22 22 Totals 673 E se !2 - $348 -3- Of the’303 injections conszdered disallowable, the physician expr%ss0d his cpimon that, 4.24 $njections should not have been paid because the nakure of the Anjeet~ons ‘WEBS not ident%faed on tie claims, and -179 inJections should not have been paid because they wem not considered to be eompatib3ve Tath acceptable and necessary treatment for the diagnosed fllnssses of the bemefzciary , The p@mician considered payments for 83 in~ectS.ons questIon- able because ad&tional information would be needed to determine that the services wema covered under Medicare. AlLhough the method used to select the Il.200 cl.aima for review does not provzde a sound basas to make a statistical projection, we believs the fo%bo~ng facts UJustrate the potential s%gnificance of this problem. --Of the 673 mpctions for which charges were mads on those claims, about 57 percent should not--in the opsnion of the SSA physic5an--have been paad or should have been hel.d in abeyance by the Medicare carrier until. further support was furrz&ed. --The charge per injection averaged about $4. --The sue carriers paid about IO.5 m-illion claims for services pronded to Medzcare patients durrng the 12-month period ending Harch 1970, --Of the sample claims selected in our revdew, about 18 percent contained charges for injections. We were addsed by the SSA physician that before claims examfners could properly datermane whether charges for injections should be covered by Medicare, the examiners need detalled guide- tines sha;ting (a) the specific k&-+tions that are considered as acceptable and necessary treatment for a particular 8XLness and (2) the frequency that injections can be administered and stil1 be an effective treatment fog the illness. Ke advised us also that, if claims examiners do not have detaIled Instructions, a nurse or medical. consultant, z.n most in&aces, would have to determine vhetheb chmges for injectxons should be coveFed. mere appears to be some misunderstanding on the part of the carrzlers as to the aIUowability of charges for drugs and biologicals protided to MedZcare beneficiaries. Because our review of claims -40 under the Aprfl, 1969 instructions was peflfoPmed at SSA headquascters and did not invo'%vs a review of the cax~ie~s~ recopds, we we~e not able to deteFmine the ressons the can‘xe~s pald for dngs and bfo- l.o~~cal.s which *peaFed questionable. we suggest, therefore, that 3% request the C~T~BLUS to explain why they aXlomc+d cha~@m for i.n~ec-tAons wh~~ch~ according to the SXA physicran, should have beemaquestioned or disalllowed, We suggest also that SSA carefully Fmw3ff the carrxx!s~ responses to determine whethex! there is a need foY' mox% specifx guideUnes on (3) the types of dx%gs and bfo- lo&d.s conrsfderad acceptable andi necess~y for the tx%atmerxt of spedffc ilbess, and (2) the aXLo~ab%e fpequeney of such inject10ns. W&tham discussed this matter with members of yotz staff and ageed to furnish them with the nfTos%ation developed during OUP retiewo We would appzseciate being advised of any actions you take on this matter and w5Ii.l. be pleased to discuss the subject f+urtheP with yact OF your staff, HF, Robert M, BaXL Commission@r of Soeia~ Security f)sp@ken% of Health, Education, and Welfare
Payments Made by Medicare Carriers for Drugs and Biologicals Furnished to Medicare Beneficiaries
Published by the Government Accountability Office on 1971-06-30.
Below is a raw (and likely hideous) rendition of the original report. (PDF)