Excluding noncovered versions when setting payment for two Part B drugs would have resulted in lower drug costs for Medicare and its beneficiaries
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Issue brief (United States Department of Health and Human Services, Office of Inspector General)
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- [Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, November 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Drug Costs Insurance, Pharmaceutical Services -- economics Medicare Part B -- economics Prospective Payment System Abatacept -- economics Certolizumab Pegol -- economics Cost Savings Injections -- economics Self Care -- economics Humans United States United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services (U.S.) Healthcare common procedure coding system
- Genre(s):
- Technical Report
- Abstract:
- Medicare coverage for outpatient prescription drugs is primarily provided under the voluntary Part D benefit. However, a limited number of prescription drugs-generally those that are injected or infused in physicians' offices or hospital outpatient settings-are covered under Medicare Part B. With certain exceptions, Part B does not cover drugs that are usually self-administered by patients, including drugs administered by self-injection. Medicare payment amounts for most Part B drugs are based on manufacturer-reported average sales prices (ASPs). In general, manufacturers must provide the Centers for Medicare & Medicaid Services (CMS) with the ASP and sales volume for each of their Part B national drug codes (NDCs) on a quarterly basis. However, Medicare sets payment amounts and reimburses providers for Part B drugs using another type of code, the Healthcare Common Procedure Coding System (HCPCS) code rather than NDCs. Because more than one NOC may meet the definition of a particular HCPCS code, CMS must first "crosswalk" manufacturers' NDCs to their matching HCPCS codes. To determine the quarterly Part B payment amount for a HCPCS code, CMS calculates a volume-weighted ASP using the ASPs and sales volumes for each of the corresponding NDCs. In some cases, "corresponding" NDCs may include versions that, despite containing the same drug/formulation, are not typically used in situations that meet Part B drug coverage criteria. In other words, under certain circumstances, criteria for including drugs in payment amount calculations may differ from criteria for covering a drug under Part B. Previous OIG work has found that inaccuracies in CMS's ASP data may have affected Medicare payments for a small number of drugs. This current data brief addresses a similar issue, whereby CMS may be including noncovered, self-administered versions (i.e., NDCs) of certain drugs when calculating Part B payment amounts.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (15 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101737981 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101737981