A private, solo practitioner allergy practice recently pleaded guilty to criminal charges and agreed to pay the government over $2 million in civil penalties for violation of the False Claims Act related to Xolair billing to Medicare and Medicaid programs.
Over a seven-year period, from 2010-2017, the allergy practice billed federal health care programs for a single-use vial of Xolair, even if a portion of the vial was not used and would normally be discarded. This was permissible under rules in effect at the time.
However, the practice then administered the unused portion of the vial to another patient and billed for that as well, effectively double billing. In addition, the practice received Xolair vials from Medicaid that were not documented as being used for Medicaid patients and apparently used them for other non-Medicaid patients.
Allergists should be aware that with the advent of pre-filled syringes, many payers are no longer reimbursing for wastage. Allergists should check with payers before billing for discarded doses of Xolair, or other biologics, to make sure they are still covered. You should never, however, bill split doses of vials that were already billed for another patient.
If your practice is audited, we can review and may be able to help with an appeal. The Advocacy Council – we have you covered.