More than half of the Medicaid payments that the State agency made to providers for full vials of Herceptin were incorrect. Of the 381 line items reviewed, 203 (53 percent) were incorrect and included overpayments of about $1 million ($710,000 Federal share), or almost a third of total dollars reviewed. The 178 remaining line items were correct.
On nearly all of the incorrect line items, providers reported the units of service for the entire content of one or two vial(s), each containing 440 milligrams of Herceptin, rather than reporting the units of service for the amount actually administered.
The providers attributed the incorrect payments to clerical and billing system errors that could not prevent or detect the incorrect billing units of service. The State agency made these incorrect payments because it did not have sufficient edits in place during our audit period to prevent or detect the overpayments.