Over a six-year period, Medicare may have spent $380 million on organs that were not ultimately used in covered enrollee transplants, according to a September HHS Office of Inspector General report.
Under federal law, Medicare can only reimburse certified transplant centers for organs used in covered transplants. However, CMS guidance relies on the assumption that any organ a certified transplant center surgically removes and then passes onto an organ procurement organization, or another transplant center, will end up used in a Medicare-covered transplant.
Looking at 180 reported Medicare-usable organs, Medicare reimbursed centers $2.8 million for 43 organs not used in covered transplants, as well as 12 organs not transplanted at all. Furthermore, two certified transplant centers could not supply documentation to back five organs, resulting in $154,210 in improper Medicare reimbursement.
OIG extrapolated its $380 million figure from the sample. The report said CMS guidance and federal law are in conflict. CMS even acknowledged this discrepancy in 2021 rulemaking, but that was was not incorporated in a final rule.
The office recommended CMS have Medicare administrative contractors recover the $154,210. The office also called on CMS to update Medicare guidance, aligning it with federal statutory requirements. While CMS agreed with OIG’s first recommendation, the agency did not take a definitive position with the second.
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