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chemotherapy drugs for both Medicare and private insurers, the
reimbursement policies of the private insurers changed
frequently, affecting the amount that petitioners actually
collected and the predictability of the billing and collection
process.
Petitioners' bills also included charges for Dr. Ishmael's
professional services,5 administration of the chemotherapy
treatments, other supplies, miscellaneous medications, and
laboratory items.
Determinations regarding reimbursement of charges were made
by Medicare and private insurers on an item-by-item basis.
Medicare and the insurance companies took similar positions
regarding some items. For example, neither Medicare nor the
insurance companies paid for unapproved chemotherapy treatments.
Thus, petitioners were reimbursed for chemotherapy drugs used
during chemotherapy treatments only if the drug administered to
the patient had been approved for that specific therapeutic
purpose.
The reimbursement policies of Medicare and the private
insurers with respect to other items differed. For example, the
extra cost incurred by petitioners for a staff pharmacist to mix
the chemotherapy treatments was not specifically reimbursed by
5Mid-Del did not bill patients or insurers for Dr. Ishmael’s
professional services. Instead, PC billed patients and insurers
for all of the doctor’s services, wherever provided.
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Last modified: May 25, 2011