The pharmacies get the snot audited out of them by Medicare. It is extreme and excessive.
Medicare allows three times a day if you are on insulin and one time a day if you are not on insulin. (Four times a day if you are on an insulin pump which may not be stated in the “test strip rules”; but Medicare WILL NOT pay for an insulin pump and/or supplies unless you are testing exactly four times a day).
. In 2011, Medicare did some sort of study and discovered it had allowed 6 million dollars in claims to be paid out “inappropriately”. There were three types of errors: 1) They paid for test strips when patient through the retail pharmacy when the patient was in the hospital. 2) They paid for test strips through retail pharmacy when patient was in a skilled nursing facility. 3) They paid for test strips for people who are “without documented diagnosis code for diabetes.”
(Ironically, one of the top five diagnoses used for #3 was insulin use. Can’t think of many- if any- reasons for someone to be on insulin without diabetes so that one is kind funny)
So now Medicare audits the pharmacies to death. in the beginning it wasn’t too bad however the strangle hold they have on glucose testing supplies is getting tighter and tighter each year.
On paper their requirements aren’t too bad, in practice though, they are insane. The prescription must contain the following elements:
That they have diabetes
What kind of blood glucose monitor they need and why they need it (that is, if they
need a special monitor because of vision problems, their doctor must explain that.)
Whether they use insulin
How often they should test their blood glucose
That isn’t too much to ask however, here’s the “extras” they also “require”:
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You cannot use a range for test supplies (such as 4-5 times a day). It must be an exact number.
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It must be a “wet” signature so if it is sent electronically and the pharmacy doesn’t receive with a copy of the “actual signature” but an electronic version then it must be done again with a “wet signature”. (To my knowledge this is not the case with anything else.)
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You must write the diagnosis code (ICD10) for the diabetes not the words “Type 1” or “Type 2” but you cannot use the diagnosis code for insulin (you have to physically write “on insulin or not on insulin”) (This one is a 50/50, depends on the auditor).
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If you have to fill out a prescription “form” there can be ABSOLUTELY no errors, cross offs, hesitations, “write over”, white out, etc. Doesn’t matter if the provider signs the errors and dates them. You do any of that and you have to start over. (It didn’t used to be this way but it kept getting stricter and stricter and stricter.
If the testing exceeds Medicare’s allotment then “officially” what is needed is:
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Basic coverage criteria for all home glucose monitors and related accessories and supplies are met; and, (That they are diabetic and are trained to use the glucose meter)
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Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and,
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Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen.
TYPES of things that may be in the actual documentation:
Names, dosages, and timing of administration of medications used to treat the diabetes;
o Frequency and severity of symptoms related to hyperglycemia and/or hypoglycemia;
o Review of beneficiary-maintained log of glucose testing values;
o Changes in the patient’s treatment regimen as a result of glucose testing results review;
o Dosage adjustments that the patient should make on their own based on selftesting results;
o Laboratory tests indicating level of glycemic control (e.g., hemoglobin A1C);
o Other therapeutic interventions and results.
REALITY
- Listed on the chart note under medications must be the test strips and lancets with all the information like it was a prescription.
- It should also be in the discussion section.
- Be sure to use the “most present tense” language such as “is currently testing” not just “is”
- Thirty days of glucose logs. (It says you have to have documentation that you reviewed the logs…Uh, no. Physical logs are a must.
- You must state justification in EVERY SINGLE NOTE even if it hasn’t changed. Such as “Patient has been testing and is currently continuing to test their blood sugars six times a day. Patient doses their insulin on a sliding scale and checks their blood sugars before each meal and then two hours after each meal to monitor insulin dosing.”
As a patient, if your prescription says you are testing four times a day. Then you’d better be testing exactly FOUR times a day. Not three. Not five. Heaven forbid, one day you test more frequently or one day you test less frequently. Oh, and there is no such things as “dud” strips (Being sarcastic). Oh, I’m sure that you never ever have to test your blood sugars again if you see they are low and treat them. If your blood sugar is 40 and you “treat” it, I guess you can just assume that everything is perfect after that. (Again, sarcasm) And NEVER, NEVER, NEVER, EVER share your test strips with your spouse (even if the are also diabetic and have their own prescription for test strips) because that is a MASSIVE mess.
CVS is probably tired of getting their money taken back by Medicare when technically the documentation most likely fits the WRITTEN requirements.
It is a sticky issue because technically, Medicare DOES allow more than three times a day for those on insulin (or one time for those on orals), doctors just have to justify it.
CVS Caremark job is to fulfill the provider’s order regardless of what it is and, since Medicare DOES allow it with documentation is not CVS Caremark place to be making those decisions.
That being said, has gotten so above and beyond ANAL about it, the pharmacies are losing large amounts of money on legitimate claims.
When this all began it was simply to insure that test strips were only being obtained in accordance with Medicare guidelines. That has ceased to be the motive and now it is about how many trumped up circumstances can the auditors to take money away.
The people to be complaining to is Medicare for making it so challenging that pharmacies don’t what to work with Medicare beneficiaries.
