OIG Review: Medicare B Drug Payments Process Antiquated
Jan 5, 2023 15:17:28 GMT
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Post by icemandios on Jan 5, 2023 15:17:28 GMT
January 3, 2023 03:40 PM EST Pharma
CMS needs to strengthen its internal controls to ensure Part B drug payment accuracy, OIG finds
Zachary Brennan
Senior Editor
The Office of the Inspector General within HHS today called on the Centers for Medicare & Medicaid Services (and CMS agreed) to improve the accuracy of its Medicare Part B drug payment data.
The recommendation comes as drug pricing transparency has been a sore spot across the US, and as OIG identified major gaps in how CMS tracks such data, noting that invalid or missing average sales price data meant that CMS “could not calculate an ASP-based payment amount for 8 percent of drug codes at least once between 2016 and 2020.”
In general, Medicare pays healthcare providers for most Part B drug codes on the basis of average sales prices (ASPs). Under the ASP payment methodology, the Medicare payment for a Part B drug code is 106% of the volume-weighted ASP for the Part B drug code.
Gaps in CMS’ oversight of this pharma-reported ASP data, however, “may continue to limit its ability to ensure the accuracy of ASP data and result in inaccurate Part B drug payment amounts,” OIG concluded.
In total, OIG found that 24% of drug codes were missing ASP data for one or more specific drugs within that code in at least one quarter between 2016 and 2020.
While the OIG report, released Monday, did not verify the accuracy of the manufacturer-reported data submitted to CMS by manufacturers, the report does note that there can be valid reasons for which manufacturers may have missing ASP data (e.g. the manufacturer reported a negative sales or ASP value or the manufacturer had no sales to report).
OIG also raised serious concerns about CMS’ manual processes, noting:
CMS’s internal controls do not include specific procedures to review the manual processes used by staff to analyze ASP data. CMS uses manual processes to select NDCs that populate certain data fields in its drug files including the ASP, sales volume, and status indicator values. CMS has not implemented a quality assurance process to review manual processes used by staff to analyze data in the background, code pricing, and payment files. However, CMS stated that it is developing an automated process to reduce its reliance on manual processes.
CMS employee reconciles Average Sales Prices (ASP)
CMS needs to strengthen its internal controls to ensure Part B drug payment accuracy, OIG finds
Zachary Brennan
Senior Editor
The Office of the Inspector General within HHS today called on the Centers for Medicare & Medicaid Services (and CMS agreed) to improve the accuracy of its Medicare Part B drug payment data.
The recommendation comes as drug pricing transparency has been a sore spot across the US, and as OIG identified major gaps in how CMS tracks such data, noting that invalid or missing average sales price data meant that CMS “could not calculate an ASP-based payment amount for 8 percent of drug codes at least once between 2016 and 2020.”
In general, Medicare pays healthcare providers for most Part B drug codes on the basis of average sales prices (ASPs). Under the ASP payment methodology, the Medicare payment for a Part B drug code is 106% of the volume-weighted ASP for the Part B drug code.
Gaps in CMS’ oversight of this pharma-reported ASP data, however, “may continue to limit its ability to ensure the accuracy of ASP data and result in inaccurate Part B drug payment amounts,” OIG concluded.
In total, OIG found that 24% of drug codes were missing ASP data for one or more specific drugs within that code in at least one quarter between 2016 and 2020.
While the OIG report, released Monday, did not verify the accuracy of the manufacturer-reported data submitted to CMS by manufacturers, the report does note that there can be valid reasons for which manufacturers may have missing ASP data (e.g. the manufacturer reported a negative sales or ASP value or the manufacturer had no sales to report).
OIG also raised serious concerns about CMS’ manual processes, noting:
CMS’s internal controls do not include specific procedures to review the manual processes used by staff to analyze ASP data. CMS uses manual processes to select NDCs that populate certain data fields in its drug files including the ASP, sales volume, and status indicator values. CMS has not implemented a quality assurance process to review manual processes used by staff to analyze data in the background, code pricing, and payment files. However, CMS stated that it is developing an automated process to reduce its reliance on manual processes.
CMS employee reconciles Average Sales Prices (ASP)