Maximus IBR determination confuses physician-administered and physician-dispensed drug, again.

I’ve written before about Maximus applying the wrong work comp fee schedule when making Independent Bill Review (IBR) determinations. Today I want to alert readers to another wrinkle in Maximus’ mis-application of the fee schedule rules governing physician-administered vs. physician-dispensed drugs.  

In a case that came to DaisyBill’s attention last month, Maximus incorrectly applied §9789.40 dispensed pharmaceutical fee schedule regulations to a physician-administered HCPCS code J7325.

To calculate the correct reimbursement for code J7325, Maximus should have used §9789.13.2 of the Physician Fee Schedule which provides rules for reimbursement of Physician-Administered Drugs, Biologicals, Vaccines, Blood Products.

Per §9789.13.2 of the Physician Fee Schedule, for reimbursement of a physician-administered drug the J-code and the accompanying NDC are used. To calculate the maximum fee for physician-administered drugs §9789.13.2(a)(2) states:  

The maximum reimbursement shall be determined using the “Basic Rate” for the HCPCS code contained on the Medi-Cal pharmacy rate of reimbursement for the date of service.

Why does this matter? In this particular case, the reimbursement amounts are very different. Although Maximus awarded additional payment to the provider, that additional amount was incorrect and much lower than it should have been. By using the wrong fee schedule, Maximus’ award to the provider was short by hundreds of dollars.

As before, we advised the provider to appeal the determination using Labor Code §4603.6, which allows an appeal within 20 days if the determination was the result of an erroneous finding of fact.

I’ve included some relevant sections of the regulations:

Labor Code 4603.6.

(f) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:
    (5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.

§9789.13.2 Physician-Administered Drugs, Biologicals, Vaccines, Blood Products

(a) Physician-administered drugs, biologicals, vaccines, or blood products are separately payable.

(1) Vaccines shall be reported using the NDC and CPT-codes for the vaccine. Other physician-administered drugs, biological and blood products shall be reported using the NDC and J-codes assigned to the product.

(2) The maximum reimbursement shall be determined using the “Basic Rate” for the HCPCS code contained on the Medi-Cal Rates file for the date of service.

§9789.13.3 Physician-Dispensed Drugs

The maximum reimbursement for physician-dispensed drugs is determined pursuant to the Pharmaceutical Fee Schedule set forth in section 9789.40 and pursuant to the provisions of Labor Code section 5307.1.

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