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Learn more about RAC Region B

Approved Audit Issues

CGI, the Medicare Recovery Audit Contractor (RAC) for Region B, identified on its website CMS approved audit issues.

The following claims will be edited automatically and monies recouped in these areas if they were billed incorrectly:

  • Excessive units - Blood transfusions
  • Excessive units - Bronchoscopy
  • Excessive units - IV hydration

Posted 9/17/09

New Exclusion from Self-Administered Drug Benefit Change

Medica implemented a coverage change for self-administered drugs received in a physician's office effective July 1, 2008.

Due to concern about the impact of this change on the administration of three self-administered drugs that are colony stimulating factors (CSFs)— Neupogen, Neulasta and Leukine—Medica has decided to exempt CSFs from its coverage change beginning June 1, 2009. As a result, Medica members will not be required to purchase these medications at a pharmacy.

This coverage change should accommodate immediate availability needs for these medications after members receive chemotherapy.

While Medica believes there are strategies for managing these challenges, Medica has agreed to allow for coverage of these drugs under either the member's medical or pharmacy benefit, effective June 1, 2009.

Note: When members receive a CSF from a physician, the member's medical benefit will apply.

WPS Updates Chemotherapy Drugs and their Adjuncts LCD (HONC-010)

WPS has updated its Medicare policy to include new language referencing compendia as sources for medical necessity and coverage. This policy is effective May 16, 2009.

The following pages and sections are of note:

  • Page 2, section A under “Indications and Limitations of Coverage and/or Medical Necessity"
  • Page 13, section G
  • Page 14, "Utilization Guidelines"
  • Page 19, “Current Compendia.”

 

 

 

 

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