Medicare Part “b” Audit Prevention- Diabetic Supplies
Recently we have been getting a lot of questions about what the documentation requirements are for diabetic supplies to satisfy Medicare audits. Here are some key things Jeff has found: Refills have to be documented whether the refill request was called in or the request was made in person Authorized Representative: must provide signature, printed name, relationship to patient, and indicate the patient was either physically or mentally unable to sign for the product Must record: Make; Model; Serial Number; Lot Number; and Expiration Date of product dispensed Prescriptions are only valid if the patient has been seen by their physician within the preceding six months If physician orders are greater than the allowable, the prescription is only valid for six months. In addition, a CMN or Detailed Written Order must be signed by the physician prior to billing Medicare If the pharmacy uses eRx Network (Allwin) or OmniSys, the patient must pick up the Rx on the date the label is printed. If the Rx is run and label printed on Monday, but the patient does not come in until Tuesday, CMS will pull back the reimbursement because the date of service started prior to the actual pickup date. Diabetic Testing logs: Must be obtained for all Medicare patients Patient testing must match the prescription If patient is testing within the allowable, you must be able to prove need of refill If patient is non-compliant with physician’s order, fill the Rx for the actual usage and zero out the refills. Patient must see physician to seek a new prescription Continue reading >>
Everything You Need To Know About Prediabetes And Diabetes Supply
Diabetes is a serious lifelong condition that may cause other major health problems if you do not keep your blood glucose under control. Whether you are a prediabetes candidate or already have diabetes, it is crucial to understand fully what supplies you need in order to monitor and control your blood glucose level, and alleviate various conditions that may exhibit along with the condition. Prediabetes Supply – Things Prediabetics Need Getting diagnosed with prediabetes is a serious wake-up call to your current health, but it doesn’t have to mean you will most definitely get diabetes. With close monitor to your blood glucose level and paying attention to lifestyle changes, you can slow down the progression to diabetes or even prevent diabetes. Physical activity is an essential part of the treatment plan for prediabetes because it lowers blood glucose levels and decreases body fat. Depending on your health insurance company policy, you may be qualified for an incentive for joining a gym or fitness program. If your insurance company does not offer an incentive, you can try asking about your working company policy and see if they have an incentive for their workers getting fit. At the same time, they may offer an incentive for going to a nutritionist and plan out a diet plan for your needs. However, if both your insurance company and your working company both do not offer incentives, you can still claim these expenses as medical expenses on your tax as long as you have documentation of these treatments being recommended by your doctor. Sleep is crucial for prediabetes candidates. Without proper amount of sleep, your body cannot use insulin effectively and may increase your chance of developing type 2 diabetes. If you suffer from sleep apnea, do seek help from your doct Continue reading >>
Comparative Billing Reports
Question Categories: What is the purpose of this comparative billing report (CBR)? CBR201609 was created to inform suppliers about their billing patterns for diabetic testing supplies (DTS). This CBR analyzed the following codes: A4235 (blood glucose test strips) and A4259 (lancets). To obtain more information about CBRs, please visit our website page at Comparative Billing Reports. Why was this topic chosen? This topic was chosen because the Office of Inspector General (OIG) has determined that DTS is an area vulnerable to fraud, waste, and abuse. A 2013 OIG report revealed that Medicare payment of $6 million for DTS claims was inappropriate. The OIG also found questionable billing by 10 percent of DTS suppliers in the amount of $425 million for Medicare-allowed claims. To review more findings from this report, select the following web link: Inappropriate and Questionable Medicare Billing for Diabetes Test Strips, OEI–04–11–00330, August 2013. How many providers received CBRs? CBRs were sent to approximately 12,000 Medicare suppliers of diabetic testing supplies. Each CBR contains a supplier’s billing history and payment patterns and compares them to their peers. Those who did not receive a CBR who would like to review one can access a mock supplier’s CBR at the web link titled, CBR201609 Sample CBR. What is the specific focus of this CBR? This CBR focuses on suppliers of diabetic testing supplies, and examined these metrics: Percentage of beneficiaries with a KX modifier and those transitioning between KS and KX modifiers Average number of diabetic supplies per day per beneficiary by Healthcare Common Procedure Coding System (HCPCS) code and KS and KX modifiers Average mileage between supplier and beneficiary and KL modifier use What codes are included in th Continue reading >>
What Does Medicare Cover For People With Diabetes?
For people with diabetes, Medicare Part B will cover blood glucose monitors, test strips, lancet devices, and lancets. In addition, glucose management solutions for those with diabetes are covered whether someone uses insulin or not. Also covered are, medical nutrition therapy and a number of hours for diabetes self-management training. Some people with diabetes may qualify for therapeutic shoe coverage and foot exams are covered once every six month as long as you haven’t seen a foot care specialist between visits. Medicare Part B also covers insulin pumps and pump supplies as well as the insulin used specifically in the pump as long as certain requirements are met. Under Medicare Part B, those with diabetes who are on insulin may get up to 300 test strips and 300 lancets every three months and those who have diabetes but don’t use insulin may get up to 100 test strips and 100 lancets every three months. You may be able to get more if your doctor says it is medically necessary and documents this need. As part of prevention care, within the first year of Part B coverage, you get coverage for a “Welcome to Medicare” physical exam. Then after that, an “Annual Wellness visit” is covered each year. During these visits, a personalized prevention plan is created and used. When you need to find out if a test, item, or service is covered, you can search it at Medicare.gov. Compare Medicare Plans now. How to Get the Brands You Need Covered by Medicare The rules of Medicare states your doctor can prescribe the specific item or brand of diabetes testing supplies you need. Your doctor must put this in writing and also make a note in your medical record indicating that you need this exact item or brand in order to avoid an adverse medical outcome. Once your doctor does t Continue reading >>
Medicare Part B
When I started at my current pharmacy, we had a certain physician who didn't want to cooperate and provide valid prescriptions for Medicare B covered items. Well maybe it wasn't the physician...the nurse would not let us speak to the physician to explain what we needed. The nurse would phone-in the orders for testing supplies and leave them on the voice mail. Which would cause us to call back and say that phone-in orders are not valid for Medicare B diabetes supply claims. We would explain that we needed a hand-written or fax order that had: the patient name the product(s) being ordered the quantity to be dispensed the testing frequency refill information and the ICD coding appropriate for the patient's condition You would think that we were asking them to fax over the patient's entire medical history in triplicate. This went on for months. Patients were receiving substandard care because some nurse was having what she believed to be a turf issue. The last thing I want to do is keep a patient from being able to test their blood glucose levels, but I'm not going to circumvent the regulations that are in place. I think it finally came down to one patient who was able to get the physician's attention on this matter. The patient asked me what I would do if I were in their shoes. I told them that if my physician wasn't willing to provide a valid prescription for my testing supplies, I would assume that they really didn't care about my condition and that I would change physicians. I handed the patient a leaflet that said what was required on the Medicare B prescriptions. The patient was on their way to the physician's office. I don't know the details of the conversation, but whenever we call now, we get what we need from that office. We could have just fudged the information Continue reading >>
Does Medicare Cover Diabetes Supplies
| Licensed since 2008 Print Are you looking for ways to manage your costs for diabetes supplies? In addition to any medications your doctor prescribes, like insulin, you also could have costs related to daily blood glucose monitoring. Fortunately, if you are enrolled in Original Medicare (Part A and Part B) or a Medicare Advantage plan, you may have coverage for some of your diabetic supplies and equipment. Here’s a summary of your benefits. Please note that this article refers to Medicare Part B. If you’re enrolled in a Medicare Advantage plan, you still get all the benefits of Medicare Part B (along with Part A benefits, all except for hospice care – which is covered for you under Medicare Part A). If you have questions, contact your Medicare Advantage plan. Does Medicare cover diabetes supplies for blood glucose testing? Diabetic supplies for blood glucose monitoring are considered durable medical equipment (DME) under Medicare Part B. In order for your diabetes supplies to be covered, they must be ordered and supplied by providers who participate in the Medicare program. In addition, in some parts of the country, Medicare has launched a new competitive bidding program for DME to help lower costs for these items. If you live in one of these areas, you must get your diabetic supplies from a contracted provider or Medicare may not pay for them. Part B may pay 80% of allowable charges for glucose monitors, glucose control solution, diabetic test strips, and lancets and lancet devices; you then generally pay 20% plus any applicable deductibles. There may be quantity limits on the number of test strips and lancets Medicare covers each month (usually 300 of each every three months if you use insulin, or 100 of each if you don’t).However, your doctor may request an Continue reading >>
Diabetes Supplies Insurance And Medicare Coverage
Topic: MEDICAID; MEDICAL CARE; PHARACEUTICAL ASSISTANCE PROGRAMS; ELDERLY; DISEASES; HANDICAPPED; MEDICARE; HEALTH INSURANCE; Location: DISEASES; INSURANCE - HEALTH; June 2, 2006 2006-R-0339 DIABETES SUPPLIES INSURANCE AND MEDICARE COVERAGE By: Helga Niesz, Principal Analyst Janet L. Kaminski, Associate Legislative Attorney You asked whether diabetic supplies must be covered (1) under the private group and individual medical insurance policies issued in this state, (2) by Medicare and whether this type of coverage is involved in the new Medicare Part D program, (3) by ConnPACE, and (4) by Medicaid. SUMMARY Connecticut law requires group and individual medical insurance policies to cover diabetic supplies. Medicare Part B also provides such coverage for seniors, including blood glucose testing monitors, test strips, lancet devices, lancets, and glucose control solutions. The new Medicare Part D prescription plans cover the prescription drugs themselves, including insulin and only those supplies needed to inject insulin, including syringes, needles, alcohol swabs, and gauze. The state's Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) program covers prescription drugs, insulin and insulin syringes; but it does not cover other diabetic supplies. The Medicaid program covers diabetic supplies; it also still covers prescription drugs and insulin for those who are only eligible for Medicaid and not Medicare. PRIVATE GROUP AND INDIVIDUAL INSURANCE COVERAGE State insurance law requires health insurance policies to cover medically necessary laboratory and diagnostic tests for all types of diabetes, including insulin-dependent, insulin- and non-insulin-using, and gestational diabetes. It requires coverage for medically necessary equipment speci Continue reading >>
Does Medicare Cover My Diabetic Testing Supplies?
The simple answer is that yes, Medicare does cover some diabetic supplies. Medicare covers diabetic testing supplies, such as: Glucose Test Strips Blood Sugar Testing Monitors Lancets Glucose Solution Avoid the Most Common Pitfalls When Buying Diabetic Supplies Many people who are new to Medicare and/or diabetes care do not realize that in order for diabetic supplies to be covered by Medicare, a prescription is required from your doctor. If you buy diabetic supplies over-the-counter without a prescription, you have to pay full price. In addition, you should purchase your diabetic supplies at the pharmacy counter (as opposed to the general retail counter) because the pharmacy has the ability to process the claim with Medicare. Also, keep in mind that Medicare will not pay for supplies if you go to a pharmacy that is not enrolled in Medicare. The Most Complete Insurance Coverage: Medigap Plan F To ensure that your insurance covers the cost of diabetic supplies, such as diabetic meters, lancets, and test strips, we recommend enrolling in excellent health insurance coverage, which includes: Medicare A & B A good Medicare Part D plan & Medicare supplement Plan F You can protect yourself from against high out-of-pocket costs by enrolling in a full coverage Medicare supplement plan, such as the Medigap Plan F policy, which covers 100% of Medicare Part B’s excess charges. It is the most comprehensive Medicare supplement plan because it covers ALL the gaps left by Medicare A & B. Without a Medicare supplement Plan F, you will most likely be responsible for the Part B deductible ($183 deductible in 2018) and any required coinsurance or copays. You should not be required to pay any out-of-pocket costs if you have Medicare A & B, Medicare Part D, and Medigap Plan F. How to Minimi Continue reading >>
Medicare Part B Vs. Part D
Johns Hopkins Advantage MD covers both Medicare Part B and Part D medications. To see examples of Part B medications and Part D medications and where to obtain the medication, view the Medicare Part B vs. Part D chart below. Diabetes testing supplies are covered under Medicare Part B. Supplies like meters, lancets, and test strips can be purchased at a network pharmacy, but nebulizers and other equipment must be purchased through a DME vendor. If you have any questions, call Customer Service. PPO members: call 1-877-293-5325 (TTY: 711) and select option 3. HMO members: call 1-877-293-4998 (TTY: 711) and select option 3. If you previously purchased diabetes testing supplies from a pharmacy without using your Advantage MD insurance, you may file a Part B claim to go through the reimbursement process. Medications Covered by Part B (medical) Medications Covered by Part D (pharmacy) Where to Obtain Medication Diabetic Supplies Diabetic Supplies 1. Blood glucose self-testing equipment and supplies (whether or not you use insulin): Blood glucose monitors Blood glucose test strips Lancet devices and lancets Glucose control solutions for checking the accuracy of testing equipment and test strips 2. Insulin pumps and the insulin used in the pumps 1. Injectable insulin not associated with the use of an insulin infusion pump 2. Certain diabetic supplies: Syringes Needles Alcohol swabs Gauze Inhaled insulin devices You may obtain Part B diabetic supplies from an Advantage MD durable medical equipment (DME) provider or any network pharmacy. To learn about how to get diabetes testing supplies, call Customer Service. PPO members: call 1-877-293-5325 (TTY: 711) and select option 3. HMO members: call 1-877-293-4998 (TTY: 711) and select option 3. Part D diabetic supplies are available fr Continue reading >>
Medicare Part B
#1 Brand used by Medicare patients OneTouch® test strips are ALWAYS covered on Medicare Part B and $0 with most supplemental health plans.* With their red, white and blue Medicare Part B card alone, your patients pay just $1.66 for a box of 50ct test strips. Continue reading >>
What Diabetic Supplies Are Covered By Original Medicare?
Original Medicare Part B covers some diabetic supplies, including: Blood sugar (glucose) test strips Blood glucose monitors, lancet devices, and lancets Glucose control solutions for checking the accuracy of test strips and monitors Insulin if you are using a medically necessary insulin pump (see below) Therapeutic shoes or inserts (see below) There may be coverage limits on the quantity and frequency you can get these supplies. Original Medicare Part B does not cover these diabetic supplies: Insulin (unless used with an insulin pump) Insulin pens, syringes, or needles Alcohol swabs or gauze About insulin coverage If you use a medically necessary external insulin pump, the insulin and the pump could be covered as durable medical equipment (DME). If you do not use a pump, you pay for all of your insulin costs. If you have Medicare prescription drug coverage (Medicare Part D), insulin and certain medical supplies used to inject insulin are covered. About therapeutic shoes and inserts Medicare Part B coverage includes therapeutic shoes or inserts for diabetics who have certain conditions -- ask the doctor who treats your diabetes if you need them. To make sure these supplies are covered by Medicare, please note: A qualified doctor (such as a podiatrist) must prescribe the shoes or inserts. A qualified doctor (such as an orthodontist) must provide and fit you for the shoes or inserts. Medicare Part B covers one pair of custom-molded shoes (including inserts) or one pair of depth-inlay shoes per calendar year. Medicare also covers two additional pairs of inserts each calendar year for custom-molded shoes and three pairs of inserts each calendar year for depth-inlay shoes. In certain cases, shoe modifications may be substituted for inserts. The supplier must have an order (pr Continue reading >>
Diabetic Services, Supplies And Documentation
Presented by Medicare Part B and DME MAC Provider Outreach and Education November 2017 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is†without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2017 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 2 Agenda • Diabetic Overview & Screening • Diabetic Self Management Training (DSMT) • Medical Nutrition Treatment (MNT) • Glucose Monitors & Testing Supplies • Therapeutic Shoes for Persons with Diabetes • External Insulin Infusion Pump • Documentation Requirements • Reminders and Resources November 2017 3 November 2017 4 Diabetic Services, Supplies and Documentation Slide Number 2 Agenda Slide Number 4 Objective Slide Number 6 Slide Number 7 Diabetic Overview �and Screening � Diabetes Overview Diabetes Screening Diabetes Screening Risk Factors Diabetic Self-Management Training (DSMT)� What is DSMT? DSMT Coverage DSMT Coverage/Coding Frequency Example 1 Frequ Continue reading >>
Compliance Is Key In Medicare Part B Audits
Medicare is a beneficial program for Americans who are over age 65 or have certain disabilities, but providers sometimes find compliance issues a challenge. An understanding of mandates and how to properly submit claims will ensure organizations are reimbursed for Medicare Part B-covered medications, equipment and supplies, such as nebulizer-inhalation medications, oral immunosuppressive drugs and diabetic testing supplies. Occasionally, providers may unknowingly submit noncompliant or even fraudulent claims for the products and services they offer. Audit Basics The Centers for Medicare & Medicaid Services (CMS), the entity that oversees Medicare, contracts with private third-party organizations, including payment, program integrity and recovery-audit contractors and benefit administrators, to manage the Medicare population of 57 million beneficiaries and mitigate the risk of audits.1 Billing errors can result in audits and providers repaying claims. According to CMS, the error rate for improper payments for equipment is 39.9 percent.2 It is important to note that most prescriptions for home medical equipment (HME) rarely provide the required information for billing Medicare. If information on prescriptions is not the same as a detailed written order (DWO), any reimbursement is subject to recoupment. A physician’s order/certificate of medical necessity (CMN) is often required before billing, and orders must comply with Medicare Local Coverage Determinations (LCDs), which detail coverage criteria and required documentation. Prescription Requirements GENERAL (PROGRAM INTEGRITY MANUAL (PIM) 5.2.1) All items billed to Medicare require a prescription, and each item must have an order signed and dated by the treating physician and kept on file by the supplier to be availabl Continue reading >>
Medicare’s National Mail Order Program For Diabetic Testing Supplies
On July 1, 2013, Medicare Part B will implement a national mail-order competitive bidding program specifically for diabetic testing supplies. [1],[2] The program applies to all zip codes in the 50 United States, the District of Columbia, Puerto Rico, U.S. Virgin Islands, Guam and American Samoa.[3] Once implemented, beneficiaries in traditional Medicare[4] will purchase diabetic testing supplies using a mail order option or a non-mail order option.[5] Included Supplies Equipment such as blood glucose test strips, lancet devices, lancet, and glucose control solutions for checking the accuracy of testing equipment and test strips and other Medicare Part B covered diabetic testing supplies are included in the national mail-order program.[6] However, Medicare Part D-covered supplies such as syringes, needles and inhaled insulin devices are not included in the national mail-order program.[7] Mail-Order Options Under the national mail-order competitive bid program, traditional Medicare beneficiaries will purchase their diabetic testing supplies through a national mail-order contract supplier ("Mail Order Option") or in person from any Medicare-enrolled supplier of non-Medicare testing supplies ("Non-Mail Order Option"). [8] Mail-order supplies will be shipped directly from the supplier to the beneficiary through a service such as United States Postal Service, Federal Express, the United Parcel Service or a mail-order contract supplier's delivery service.[9] Beneficiaries can find suppliers at Medicare Part B will reimburse mail-order deliveries provided that they are delivered directly from the supplier to a beneficiary's residence.[10] Beneficiaries who select the Mail-Order Option cannot have diabetic testing supplies shipped to a pharmacy and then have the pharmacy deliver Continue reading >>
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When you have diabetes, accuracy matters. Stick with the brand you trust—don't let them switch your test strips! Some test strip suppliers may tell you otherwise, but Accu-Chek products are still covered by Medicare Part B at the same low co-pay1 as all other brands.2 They may even try switching you to another brand. They’re not concerned about you—they’re doing it to benefit their own bottom line. You can take some simple steps to preserve your choice and ensure you’re not switched to a low-quality product: Say "no," if your strip supplier tries to switch you to another brand. At your next visit, ask your doctor to specify Accu-Chek test strips by name on your prescription. Ask for Accu-Chek strips by name from your test strip supplier. If they no longer carry Accu-Chek test strips, you can purchase them from local retail pharmacies. For a list of retailers that offer Accu-Chek products, visit our Where to Buy page. Get smart answers about Medicare changes Medicare has changed how mail-order customers get diabetes testing supplies. Here's what it means for you. What if my mail-order supplier tells me I need to switch to another brand? You do NOT have to change brands. Patient protection rules exist to help ensure that you have access to the supplies you know and prefer to use. The anti-switching rule requires contract suppliers to furnish the brand of testing supplies that work with the monitor currently in use by the patient. It was established to protect patient and physician choice of glucose monitors. If the supplier you contacted doesn't carry Accu-Chek products, visit your local retailer to purchase your Accu-Chek test strips. Am I required to get my strips through mail order? No. Medicare Part B patients can get diabetes testing supplies from a retail Continue reading >>
