Department of Health
Medicaid Reimbursement of Synagis Synagis is a prescription medication that helps to decrease the incidence of human respiratory syncytial virus in children who were born prematurely or diagnosed with serious respiratory conditions such as congenital heart disease or chronic lung disease. Synagis costs an average of about $2,000 per month per recipient.
We audited the Medicaid payments for Synagis over a three-year period and identified about $29.7 million in payments that did not comply with the Department of Health’s guidelines for the use of the drug. For example, some of the payments were for dosages that exceeded the recommended levels. Some of the non-compliant payments may have been medically necessary in the circumstances, but others may not have been necessary. We examined the payment controls established by the Department to determine whether they provided reasonable assurance the payments were, in fact, medically necessary. We identified a number of weaknesses in these controls and concluded that they provided no such assurance. We recommended that the Department strengthen the controls to provide assurance such payments are appropriate.
For a complete copy of Report 2008-S-153 click here.
For a copy of the associated follow-up report click here.