Department of Health

Medicaid Reimbursement of Synagis (Follow-Up)

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.

In audit report 2008-S-153, we examined 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 (Department) guidelines for the use of the drug. 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. When we followed up with Department officials, we found they have made progress in correcting the problems we identified in our initial report and have implemented all of our recommendations.

For a complete copy of Report 2010-F-46 click here.
For a copy of the 30-day response click here.