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Medical Review:

Medical Review Push Threatens Diabetic Supplies Claims

Published on Thu Mar 11, 2004

Patient logs key to surviving scrutiny.

If your claims for diabetic testing supplies are going through the wringer, you're not alone.

Durable medical equipment regional carrier CIGNA HealthCare Medicare Administration recently increased its medical review for glucose monitoring supplies, CIGNA Medical Director Dr. Robert Hoover, Jr. tells Eli.

The increased scrutiny came about because "Comprehensive Error Rate Testing (CERT) shows glucose monitor supplies to be the third highest ranked DME category for paid claims errors in DMERC Region D," CIGNA says in an article posted on its Web site.

The DMERC "has increased its efforts to review claims on a prepayment basis" when the amount of test strips used exceeds the limits set by the Centers for Medicare & Medicaid Services in a 2002 program memorandum and by CIGNA's local medical review policy (LMRP) on the items.

So, if your non-insulin treated diabetic clients need more than 100 strips or 100 lancets in a three-month period, or your insulin-treated clients need more than 100 strips or 100 lancets in a one-month period, the claim is highly likely to go under medical review.

To secure coverage for testing supplies over the guideline amount, CIGNA's LMRP requires all of these in addition to the regular coverage criteria:

  • the treating physician must order the higher amount and document in the medical record the reason for the above-guideline use;

  • the treating physician must see the patient and evaluate her diabetes control within six months prior to the above-guideline order; and

  • documentation must be in the physician or supplier record showing "the patient is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed," the LMRP says. The preferred documentation appears to be a patient log of testing.

    One supplier who was audited for diabetic supplies also was asked by CIGNA to furnish proof that the patient was trained on the monitor, adds Nicole Thiroux with DMExpress Billing Service in Northridge, CA.

    And CIGNA isn't alone in these requirements. DMERC Palmetto GBA has enforced such rules in medical review "for some time now," notes Sarah Lott, president of Texas Star Medical Billing Inc. in Vidor, TX.

    At an Open Door Forum last June 25, CMS said suppliers should expect to have to furnish documentation justifying the need for additional strips above the guideline limit set in its 2002 memo (see Eli's HCW, Vol. XII, No. 26, p. 207).

    Review Hits Provider Hard

    Having company in medical review misery is no comfort to Kathy Fiscina of Diabetic Supply of America in Naples, FL. Fiscina has seen a massive amount of diabetic supply claims held up due to the overutilization guidelines, she tells Eli.

    "The money is just hanging and hanging," severely affecting her company's daily operations, Fiscina says. It takes precious resources to put together quick responses to the medical review development requests, and then the claims stay in review for a long time - delaying vital dollars.

    When CIGNA finally reviews the claims, it often denies them if the documentation doesn't include a patient log.

    "Reviewers are overriding doctors' orders" for the amount of supplies needed, Fiscina protests. "They are harassing legitimate suppliers."

    "When people get caught" in a medical review focus area, "it can be painful," notes Asela Cuervo of the American Association for Home-care. "The DMERCs need to tell providers what they are doing."

    "DMERCs often don't tell suppliers when they are changing the rules," agrees Joan Cross, vice president of the Florida Association of Medical Equipment Services.

    It is the requirement to have patient logs that is the most taxing on suppliers. It's often hard to procure logs from beneficiaries, Cross notes.

    But if the patient uses a glucose monitor that records the readings, as many do, logs printed out from that record can be used, Lott points out.

    Thiroux's audited client was happy to find out its customer and physician used software that interfaced with the monitor to keep the utilization log. "The patient log was clear and easy to read," she says. But such software costs money, and suppliers can't depend on their clients and their doctors using it.

    Fiscina argues that patient logs shouldn't be mandatory at all, since they aren't specifically required in law or regulation.

    "Region D is disregarding physicians' orders," she insists. "Who is the reviewer to override what the doctor wants the patient to test?"

    LMRP Spells It Out, DMERC Says

    But the patient log requirement and the other two overutilization criteria were included in a March 1999 revision to the CIGNA LMRP, Hoover points out. The policy was promulgated with the usual notice and comment requirements.

    And the DMERC took pains to post a notice about the increased review of the testing items on its Web site so providers could know what to expect, Hoover maintains.

    CIGNA has been trying to spread the word in other ways as well, he adds. "If you've heard me speak over the past 12 to 18 months, you'd know that CIGNA Medicare is concentrating on the areas of glucose monitoring supplies, ostomy supplies, urological supplies and nebulizer drugs," Hoover explains. "I even go so far as to tell the audience that this is the most important part of my talk because I'm coming right out and telling them what claims are most likely to be developed and reviewed in the coming months."

    Editor's Note: CIGNA's article is at www.cignamedicare.com/dmerc/mr/CERT/glucose.html.

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