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). Medicare allows for patient’s to exceed that if it is documented in the patient’s chart file. What many patients (and providers) don’t realize is Medicare audits the BAHOOEY out of pharmacies. 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 “without documented diagnosis code for diabetes.”
(I had to laugh at #3 because one of the top five reasons given (instead of diabetes) with the last one was: “Chronic long term use of insulin.” I can’t think of many reasons that a person would be using insulin without having a diagnoses of diabetes and anyway, anyone using insulin, regardless of the diagnosis, should be allow to test their blood sugars.)
So now Medicare audits the pharmacies to death. (They even audit the pharmacy twice on the same patient in a 30 day period).
Medicare lays out it’s requirements for the “documentation” and, on paper, it doesn’t look TOO bad and, in the beginning it wasn’t.
This auditing process originally started to make sure that the government wasn’t paying out claims where they shouldn’t but it has taken on a life of its own.
Knowing the documentation required, I would say that the vast majority of the providers don’t submit documentation that is up to the Medicare test strip police’s exacting standards. Don’t get me wrong, I think that most provider’s documentation is more than adequate to answer the question of whether the test strips are medically necessary it just that as time as passed and more and more providers are meeting that documentation requirement, the auditors are being hard pressed to find things “wrong” and so are nit-picking over the slightest thing.
Here are the requirements for the prescription:
There must be a written order for all testing supplies. The written order must contain the
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 sounds simple but here’s the “extras” that are also “required”:
You cannot use a range for test supplies (such as 4-5 times a day). It must be an exact number.
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.)
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).
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:
- 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)
- 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,
- 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 documentation:
Names, dosages, and timing of administration of medications used to treat the
o Frequency and severity of symptoms related to hyperglycemia and/or
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
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.
ALTHOUGH, “Not every patient medical record will contain all of these elements; however, there must be enough information in the patient’s medical record to support the medical necessity for the quantity of item(s) ordered and dispensed.”
- 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). 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. (Again, being
CVS is probably tired of getting their money taken back by Medicare when technically the documentation most likely fits the WRITTEN requirements.
The whole thing is a Catch-22. CVS is not the patient’s medical doctor. It is not up to them to determine what is medically necessary.
That being said, they are a business, and if they are losing significant amounts of money because of Medicare auditors’ overzealous enforcement, then I get that they can no longer deal with this.
If you want to complain, you need to be complaining to Medicare for making it so difficult that pharmacies don’t what to support Medicare patients. Personally, I’d love to do a study of how much money Medicare has taken back inappropriately when documentation fits the requirements that as they are written. I can bet it is a lot.