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October 16, 2009

State Overspent $30 Million For Respiratory Drug

Health Department Failed to Enforce Guidelines for Synagis Use

New York State spent almost $30 million more than it should have on a drug to prevent lung infections in premature infants because of deficiencies in the state’s processing system, according to an audit released today by State Comptroller Thomas P. DiNapoli.

“New York doesn’t have health care dollars to waste,” DiNapoli said. “Every one of those dollars needs to be spent the right way, especially when they’re targeted toward helping babies stay healthy. The Department of Health (DOH) has to do a better job of enforcing its own guidelines and standards. In these tough fiscal times, any amount of waste is too much.”

DOH guidelines state that the drug Synagis should be given to children less than two years of age at the beginning of the human respiratory syncytial virus (RSV) season, and that no more than five monthly doses should be received by the child during the season. These guidelines closely reflect the guidance provided by other states and MedImmune, the manufacturer of Synagis.

DOH guidelines also limit a pharmacy’s ability to dispense and bill Medicaid for a new monthly dose within 21 days of the prior dose of Synagis being dispensed.

Synagis, which costs around $2,000 a month for each individual, helps decrease the incidence of RSV in infants that were born prematurely, or were diagnosed with serious respiratory conditions such as congenital heart disease or chronic lung disease. RSV occurs in New York primarily between November and April and can often lead to respiratory tract infections or pneumonia in infants.

DiNapoli’s auditors found that from July 1, 2005 to June 30, 2008, approximately $29.7 million of the $146.5 million in Medicaid paid claims for Synagis did not follow DOH guidelines. The Medicaid program reimbursed pharmacies $17.9 million for Synagis claims outside of the RSV season, paid $6.2 million for claims in excess of the five monthly doses allowed, paid $3.3 million in pharmacy claims for children over the age of two and paid $2.3 million in claims for medication doses less than 21 days apart.

The audit recommends DOH:

  • Take steps to ensure compliance with issued guidelines relating to duration of the RSV season, age of the individual receiving Synagis, and the number of doses an individual receives;
  • Monitor eMedNY to ensure it is not being excessively overridden to allow for the early refill of prescriptions; and
  • Use a newly developed prescriber education program to communicate Synagis guidelines and controls.

DOH generally agreed with the audit’s findings and have begun to implement its recommendations.

The audit is available at:

About the State Comptroller’s Medicaid Audits
The Office of the State Comptroller conducts regular audits of the state’s $45 billion Medicaid program. In 2009, DiNapoli’s auditors have identified $28.8 million in overpayments and savings. Auditors review Medicaid claims that have been submitted by service providers and identify billing patterns and other circumstances that warrant an examination to determine whether claims are valid and appropriate.


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