OIG: CMS Paid $21 Million Too Much for Wound Pumps

BALTIMORE–CMS paid more than $21 million in improper claims for
negative wound therapy pumps and accessories in 2004, the Office of
Inspector General said in a report released Monday.

The OIG reviewed payments for the pumps after claims shot up by
444 percent between 2001 and 2005, from $25 million to $136
million.

In its report, “Medicare Payments for Negative Pressure Wound
Therapy Pumps,” the OIG found that nearly a quarter of all the 2004
claims did not meet Medicare requirements. Most of the improper
claims had insufficient documentation, the report said. For 44
percent of the claims, supplier-prepared statements were not fully
supported by patients’ medical records, the OIG said.

The review was based on a random sample of 378 pump claims from
CMS’ National Claims History file with dates of service in
2004.

While the DMERCs had some safeguards in place to prevent
improper payments, they were different among the four contractors,
the OIG found.

Based on its review, the OIG recommended that CMS conduct
additional medical reviews of claims for the pumps and look at
medical records instead of only supplier-prepared statements. CMS
should also educate suppliers and wound care providers about use of
the pumps and the documentation necessary for medical records, the
OIG said.

The OIG further recommended that CMS:

• consider establishing advance coverage determinations for pump
  claims from suppliers with a high number of claims for the
  equipment or who have been denied or have a pattern of
  overuse.
• require face-to-face exams of patients, or require suppliers to
  get certain parts of patients’ medical records from physicians to
  support the medical necessity of the pumps.
• consider strengthening coverage criteria for the pumps and
  increase prepayment reviews of claims for them.

CMS said it agreed with some of the OIG’s recommendations:
making claims reviews for the pumps a priority, requiring that
medical reviews be based on entire medical records and directing
contractors to enhanced education about use and coverage of the
pumps.

However, the OIG said CMS did not agree with the other
recommendations because they could bring about delays in providing
the pumps to patients.

To download a pdf of the report, click here.