Investigators target infusion providers
AMARILLO, Texas - Some state attorney general offices have begun launching criminal investigations against infusion providers who they claim have billed too much for Synagist, a powerful and very expensive antibiotic for young children with respiratory syncytial virus (RSV), said industry attorney Jeff Baird.
The problem here, it seems, involves an unclear billing scenario. Synagist costs $1,052 for a 100mg vial and comes in two vial sizes, 50 mg and 100mg. Issues arise when a patient requires only a portion of a vial. Can providers combine the leftover drug as part of another order? And if so, since pharmacies can bill only for 50mg of 100mg vials, how do they bill for a patient that requires say, 82mgs?
In this instance, if a pharmacy fills a prescription for 82mgs, but bills for two 50mg vials, "it can look like they are doing something wrong," said Baird, who works with Brown & Fortunato in Amarillo, Texas.
In many states, Medicaid programs are vague on how pharmacies should handle wastage (leftover drug) and how they are supposed to bill for it. With a drug as expensive as Synagist, some states become particularly sensitive to the possibility of double dipping.
"We have seen some state AGs launching criminal trials, saying pharmacies appear to be upcoding and billing more than they should," Baird said. "We come in and say they are doing just what they are supposed to be doing."
On a case-by-case basis, Baird said, he's finding some success arguing that pharmacies must bill on a per vial basis, not milligram basis.