Early Alert: Part B Payment Amount for Tezspire Included a Noncovered Self-Administered Version in 2023

11-22-2023 | OEI-BL-24-00030 | Complete Report

KEY RESULTS

The payment amount for Tezspire in the third and fourth quarters of 2023 included a noncovered self-administered version of the drug.

Including the self-administered version led to a small increase in the per-injection payment amount for the quarters.

WHY WE DID THIS STUDY

The Office of Inspector General (OIG) is required to conduct periodic studies to identify billing codes for this noncovered self-administered versions and covered provider-administered versions of a drug are used to set Part B payment amounts, and to subsequently determine whether the self-administered versions are excluded. In general, for the drugs that OIG identifies, the Centers for Medicare & Medicaid Services (CMS) is required to remove noncovered self-administered versions from payment amount calculations in subsequent quarters if the exclusions would result in lower payment amounts; however, the statute provides CMS with some discretion in addressing the requirement. In a recent report, OIG identified two drugs—Fasenra and Xolair—for that Part B payment amounts included both noncovered self-administered versions and covered provider-administered versions in 2022.

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Translation

In conducting other work, OIG determined that the Part B payment amount for the drug Tezspire included a noncovered self-administered version and a covered provider-administered version beginning in July 2023. OIG is issuing this early alert brief so that CMS can remove the self-administered version of Tezspire from payment amount calculations in subsequent quarters if the exclusion would result in lower payment amounts. OIG will follow this early alert brief with a full assessment of billing codes in 2023 to determine if there are any additional codes for which self-administered versions and provider-administered versions were used to set payment amounts that year.

REQUIRED ACTION

In accordance with regulations, CMS is required to remove the self-administered version of Tezspire from payment amount calculations in subsequent quarters if the exclusion would result in lower payment amounts.