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patient visit, petitioner's staff prepares a physician's
statement known as a "charge sheet", which is the document from
which petitioner's billing department generates its bills. The
charge sheet specifically lists the type, amount, and cost of
chemotherapy and other drugs administered, and the type and cost
of all professional services rendered. The charge sheets are
specific as to the particulars of chemotherapy treatments so as
to comply with the guidelines of Medicare and the private
insurance industry. Petitioner submits the charge sheets
directly to Medicare or other responsible party, and petitioner
bills its patients for the copayments or other charges not
covered by insurance.
Medicare and private insurers analyze on an item-by-item
basis whether to reimburse the charges shown on the charge
sheets. The dollar amount reimbursed for a drug administered to
a patient is ascertained by reference to the average wholesale
price (AWP) of the units in which the drug is packaged and sold
wholesale, which AWP is published annually with quarterly
updates. Generally, the reimbursement amount for drugs equals
the AWP times the units used, with rounding up to the next whole
unit of a drug when billing for administration of a partial unit.
It is common industry practice to charge for all medical
services provided even when the health care provider anticipates
it will not be paid in full for all charges. The standard charge
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Last modified: May 25, 2011