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092610 1 (1971-06-30)

handle is hein.gao/gaobacwmh0001 and id is 1 raw text is: UNITED STATES GENERAL ACCOUNTING OFFICE WASHINGTON, D C 20548 CIVIL DIViSION JUN 3 0 1971 Dear Mr. Ball: We have reviewed selected payments made by Medicare carriers for drugs and biologicals furnished to Medicare beneficiaries to find out whether the charges allowed were in accordance with Social Security Administration (SSA) criteria. A sample of claims paid by the following carriers were selected for review. --Aetna Life Insurance Company, Portland, Oregon --Blue Shield of Florida, Inc., Jacksonville, Florida --California Physicians' Service, San Francisco, California --Group Medical and Surgical Service, Dallas, Texas --Metropolitan Life Insurance Company, Utica, New York --Pan American Life Insurance Company, New Orleans, Louisiana An SSA physician assisted us in our review. From the sample, the physician reviewed those claims which involved charges for drugs and biologicals and indicated his opinion as to whether, based on available documentation, the carrier should have paid for those services. MSDICARE COVERAGE OF DRUGS AND BIOLOGICALS Title XVIII of the Social Security Act provides, in part, that Medicare coverage of drugs and biologicals shall include: '4$Haservices and supplies (including drugs and biologicals which cannot, as determined in accord- ance with regulations, be self-administered) fur- nished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians[ offices and are commonly either rendered without charge or included in the physicians' bills*** Initial instructions issued by SSA in July 1966 provided that drugs and biologicals were covered only if they were of the type that could not be self-administered by injection. Vaccinations or innoculations were covered if they were directly related to treat- ment of an injury or direct exposure such as antirabies treatment, tetanus, antitoxin, etc. SSA instructed its regional offices in April 1968 that the determination of whether the drugs or biologicals are of the type S DCUMENT AVAILABLE 50TH ANNIVERSARY 1921-1971

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