High Cost Drug Billing Errors
Issue
Pegfilgrastin (J2505), a high cost drug used to prevent infections in
chemotherapy patients, is administered in 6mg doses. However, the billing unit
for J2505 is 1 unit for every 6mg administered. Frequently, providers do not
convert the dose administered to the proper billing unit, resulting in a
significant overpayment. A common mistake is for a provider to bill for 6 units
of J2505, resulting in the health plan paying 5 times more than they should.
Financial Impact
The reimbursement for each dose of J2505 is approximately $3,000, which means
the average payment for 1 dose is overstated by approximately $15,000. The
numbers add up quickly -- In 2006, Connolly Healthcare identified over $12
million dollars in overpayments for this specific drug alone.
Conclusion
J2505 and other high cost drugs have been identified as a common overpayment
problem for many health plans. There are over 10,000 drugs with different
indications and guidelines for appropriate use, creating the potential for
significant billing errors and overpayments. In fact, many drugs require complex
dosage requirements based on factors such as the patient’s weight, making the
task of ensuring accurate payment even more challenging.
Many health plans seek assistance in identifying and reducing
overpayments. As a recovery audit expert, Connolly Healthcare has the experience
and tools necessary to uncover these and other types of billing errors, recover
lost profits, and assist in fixing the problems so that the same errors do not
reoccur.
To learn more about these and other topics and how Connolly can help your
organization, contact Connolly today.
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