OIG Scrutinizes South Florida Inhalation Drug Spending

WASHINGTON — While only 2 percent of Medicare
beneficiaries live in South Florida, the area accounted for 17
percent of Medicare’s total spending for inhalation drugs in 2007,
according to an HHS Office of Inspector General report.

Released Tuesday, the report — “Aberrant Claim Patterns for Inhalation Drugs in South
Florida” — said Medicare spent an average of five times
more per beneficiary on inhalation drugs in South Florida compared
to the rest of the country, with the greatest spending differences
attributable to levalbuterol and budesonide.

In addition, the OIG said beneficiaries listed on 62 percent of
the area’s inhalation drug claims did not have an office visit with
the prescribing physicians in the previous three years.
Three-quarters of the beneficiaries receiving budesonide also
frequently exceeded coverage guidelines set in the local coverage
determination for a 90-day period.

Among paid inhalation drug claims, the report said Medicare
spent $4,400 per South Florida beneficiary compared with $815 in
the rest of the country. In Miami-Dade County in 2007, Medicare
paid $143 million for inhalation drugs, 20 times more than the
amount paid in Cook County (Chicago), Ill., the county with the
next-highest total payments. But the report noted twice as many
beneficiaries live in Cook County as Miami-Dade.

In its report, the OIG recommended “CMS ensure that its
contractors are enforcing the coverage guidelines for inhalation
drugs, eliminate Medicare’s vulnerability to potentially fraudulent
or excessive inhalation drug claims in South Florida and review
cases where the DME supplier appears to be fraudulently billing
Medicare for inhalation drugs.”

In a response, CMS Acting Administrator Charlene Frizerra said
the agency concurred with the recommendations and noted a
“medically unlikely” edit for budesonide implemented in September
2008 had decreased improper payments for the drug by half in
Miami-Dade and Broward counties. She also said the DME MAC “is in
ithe process of reviewing its experiences with the edit to see
whether the edit tolerances can be tightened.”

Frizerra described the efforts by CMS’ Miami and Los Angeles
field offices to identify suppliers whose beneficiaries had no
clinical relationship with the physicians listed on DME claims, and
to revoke the Medicare billing numbers for suppliers not meeting
supplier standards.