CMS made $21 million in pump overpayments

Friday, August 31, 2007

WASHINGTON - Nearly 25% of claims for negative pressure wound therapy pumps didn't meet Medicare coverage criteria, resulting in $21 million in improper payments in 2004, according to a review released in July by the Office of the Inspector General (OIG).
The review was triggered by a 444% increase in Medicare-allowed payments between 2001 and 2005, from $25 million to $136 million. It was based on a random survey of 378 pump claims filed in 2004.
The review also found that in 44% of claims "the information on the supplier-prepared statement was not fully supported by the medical record."
Based on the review, the OIG called for additional reviews of pump claims and for CMS to look at medical records instead of just supplier prepared statements. CMS should also educate suppliers about appropriate use of the pump and what needs to be documented in the medical record, said the report.
In addition, CMS should:
* Consider establishing advance coverage determinations for suppliers that have a high number of denied claims or a pattern of overuse.
* Require face-to-face exams with physicians or require suppliers to obtain medical records that support medical necessity.
* Strengthen coverage criteria and increase prepayment reviews of pump claims.