Home Health & Hospice Week

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 [...]