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: