OIG Finds Fault with Atypical Antipsychotic Medicare Claims in Nursing Homes
A new report from the Office of Inspector General (OIG) evaluating the extent to which nursing home residents receive atypical antipsychotic drugs found 51 percent of Medicare claims for these drugs were erroneous during a six-month period in 2007. This amounted to $116 million in unnecessary costs, according to the report, which was requested by Sen. Chuck Grassley (R-Iowa).
“Senator Grassley expressed concern about atypical antipsychotic drugs prescribed for elderly nursing home residents for off-label conditions (i.e., conditions other than schizophrenia and/or bipolar disorder) and/or for residents with the condition specified in the FDA boxed warning (i.e., dementia),” the report read.
According to the OIG, around 1.4 million atypical antipsychotic claims during the review period of January through June 2007 were for elderly nursing home residents diagnosed with conditions that were off-label (83 percent) or diagnosed with dementia (88 percent), which is specified in the FDA boxed warning. A review of medical records found more than 726,000 of the 1.4 million atypical antipsychotic claims for nursing home residents (51 percent) did not comply with Medicare reimbursement criteria.
The OIG made four recommendations to the Centers for Medicare & Medicaid Services (CMS):
1. Facilitate access to information necessary to ensure accurate coverage and reimbursement determinations
2. Assess whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes
3. Explore alternative methods beyond survey and certification processes to promote compliance with Federal standards regarding unnecessary drug use in nursing homes
4. Take appropriate action regarding the claims associated with erroneous payments identified in the sample
“CMS concurred with the second, third, and fourth recommendations,” the OIG report read, “however, CMS did not concur with the first recommendation and expressed several general concerns with the report.”
In regards to the first recommendation, CMS stated that diagnosis information is not a required data element of pharmacy billing transactions nor is it generally included on prescriptions.
The OIG countered, saying that without access to diagnosis information, CMS cannot determine the indications for which drugs were used, and CMS is therefore unable, absent a medical review, to determine whether claims meet payment requirements.
Full OIG report: “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents” (PDF format)