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Audit (A-09-11-02027)

Medicare Contractors Lacked Controls To Prevent Millions in Improper Payments for High Utilization Claims for Home Blood-Glucose Test Strips and Lancets

Executive Summary

This report summarizes the results of our individual reviews of the 4 contractors that processed claims for home blood-glucose test strip and/or lancet supplies (test strips and lancets) for Jurisdictions A through D, which included all 50 States, 5 territories, and the District of Columbia. Medicare Part B covers test strips and lancets that physicians prescribe for diabetics. The quantity of test strips and lancets that Medicare covers depends on the beneficiary's usual medical needs.

For calendar year 2007, based on our analyses of our individual samples of the four contractors, we estimated that the contractors improperly allowed for payment a total of approximately

$271 million in claims that we identified as high utilization claims for test strips and/or lancets. Of this amount, we estimated that the contractors improperly paid a total of approximately $209 million to suppliers.

Of the 400 sampled claims for test strips and/or lancets that we reviewed at the 4 contractors,

303 claims (76 percent) had 1 or more deficiencies, including (1) the quantity of supplies that exceeded utilization guidelines was not supported with documentation that specified the reason for the additional supplies, the actual frequencies of testing, or the treating physicians' evaluation of the patients' diabetic control within 6 months before ordering the supplies; (2) there was no supporting documentation that indicated refill requirements had been met; (3) physician orders were missing or incomplete; or (4) proof-of-delivery records were missing.

We recommended that CMS (1) ensure that contractors implement system edits recommended in our individual reports, (2) ensure that contractors are enforcing Medicare documentation requirements for claims for test strips and/or lancets, and (3) consider the results of our reviews when developing and evaluating coverage and reimbursement policies related to test strips and lancets. CMS concurred with all of our recommendations.

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