Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
WOUND  CARE SUPPLIES:

OPERATION  RESTORE TRUST  DATA

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> OEI-03-94-00792  OFFICE OF INSPECIOR GENERAL 
The  mission  of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the  Department  of Health  and Human  Semites  (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  served  by those  programs.  This 
statutory  mission  is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by four  OIG  operating  components:  the  Office of Audit Services, the 
Office  of Investigations,  the  Office of Civil Fraud  and Adminsitrative  Adjudicationand  the 
Office  of Evaluation  and Inspections.  The  OIG  also informs  the  Secreta~  of HHS  of program 
and management  problems  and recommends  courses  to correct  them. 
OFFICE OF AUDIT  SERVICES 
The  OIGS  Office of Audit  Services  (OAS)  provides  all auditing  services  for HHS,  either  by 
conducting  audits with its own audit  resources  or by overseeing  audit  work  done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractors  in 
carrying  out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efficiency throughout  the  Department. 
OFFICE OF INVESTIGATIONS 
The  OIGS  Office  of Investigations  (01)  conducts  criminal,  civil, and administrative

investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of

unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions,

administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud

control  units which investigate  and prosecute  fraud  and patient  abuse  in the  Medicaid  program.

OFFICE OF EVALUATION  AND INSPECITONS 
The  OIGS  Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called  inspections)  that  focus on issues of concern  to the  Department, 
the  Congress,  and the  public.  The  findings  and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the  efficiency, vulnerability, 
and effectiveness  of departmental  programs.  This report  was prepared  in the  Philadelphia 
Regional  Office  under  the  direction  of Robert  A. Vito,  Regional  Inspector  General. 
PHILADELPHIA  REGIONAL  STAFF  HEADQUARTERS  STAFF 
Robert  A. Baiocco,  ProgramAnaZyst
 Stuart  R. Wright,  ProgramSpecialist 
Linda  M. Ragone,  ProgramAnaZysi
 Barbara  Tedesco,  TechnicalSupporl Staff 
Cynthia  Hansford,  ProgramAssistant
 Brian  P. Ritchie,  TechnicalSuppoti Staff 
Emily Tseng,  Intern
 Linda  Moscoe,  TechnicalSuppoti Staff 
Neil Montovani,  Intern

Won  Jong  Oh, Intern

To obtain a copy of this repo~  please call the PhiladelphiaRegional Office at (800) 531-9562.  Depatiment  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
WOUND  CARE SUPPLIES:

OPERATION  RESTORE TRUST  DATA

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PURPOSE 
This  report  identifies  questionable  billing practices  and  describes  supplier  and  nursing 
home  practices  that  can  lead  to questionable  payments  under  the  Medicare  Part  B 
wound  care  benefit  in the  five States  targeted  by Operation  Restore  Trust:  California, 
Florida,  New  York,  Illinois,  and  Texas. 
BACKGROUND 
Wound Ckre Supplies 
Wound  care  supplies  are  protective  covers  or fillers that  treat  openings  on the  body 
caused  by surgical  procedures,  wounds,  ulcers,  or bums.  The  Health  Care  Financing 
Administration  (HCFA)  reimburses  for wound  care  supplies  under  Medicare  Part  A 
through  its payments  to nursing  homes  and  home  health  agencies  and  Medicare  Part 
B through  its payments  to  suppliers.  The  HCFA  broadened  its coverage  policy  on 
March  30, 1994, allowing  payment  for secondary  as well as primary  dressings  and 
expanding  the  procedures  that  require  dressings  to non-physician  treatments. 
We  selected  claims  for  a 1 percent  sample  of beneficiaries  who received  wound  care 
supplies  between  June  1994, the  start  of fee  schedule  reimbursements,  and  February 
1995.  We  applied  proposed  DMERC  draft  guidelines  to these  claims  to identify 
questionable  billing  practices.  We  also  collected  data  from  a stratified  random  sample 
of 420 nursing  homes  from  HCFAS Online  Survey  Certification  and  Reporting  system. 
O~ation  Restore llust 
This  inspection  was conducted  as part  of Operation  Restore  Trust.  Operation  Restore 
Trust  is a health  care  anti-fraud  demonstration  project  developed  within  the  U.S. 
Department  of Health  and  Human  Services  by the  Office  of Inspector  General,  the 
Health  Care  Financing  Administration,  and  the  Administration  on Aging.  Its aim  is to 
coordinate  Federal  and  State  resources  to attack  fraud  and  abuse  in home  health 
agencies,  nursing  facilities,  and  durable  medical  equipment,  including  wound  care 
supplies  in the  five States  with  the  largest  Medicare  expenditures. 
The  general  findings  of our  study  are  contained  in two other  reports  which  highlight 
questionable  billings  and  potentially  abusive  marketing  practices.  In this report,  we 
have  compiled  our  data  for the  five Operation  Restore  Trust  States.  By reviewing  this 
data,  the  Operation  Restore  Trust  partners  responsible  for reviewing  fraud  and  abuse 
in each  of the  five States  may be  able  to  determine  what  problem  areas  regarding 
supplier  and  nursing  home  practices  exist in their  State. 
1  Over $22 &n  of $65 &n  in questibnublepaymentsfor wound care supplies 
between Jm  1994 and Febmmy 1995 wasfound in thejive O~ration R@ore  ?hst 
States. 
Excessive  utilization  of wound  care  supplies  was found  in 62 percent  of the  total 
Medicare  allowances  in Operation  Restore  Trust  States.  Significantly  higher  costs  per 
beneficiary  was found  in Illinois.  For  all States,  $65 million  of the  $98 million  in 
Medicare  Part  B allowances  for wound  care  supplies  exceeded  the  proposed  DMERC 
guidelines. 
Woundcare activityh  Option  Restore lhxstStat@isconcentratedbyp&G  suppk, 
andplizceof service. 
Hydrogel  wound  care  products  account  for  41 percent  of the  questionable  Medicare 
allowances  for non-tape  supplies.  Almost  half  of the  excessive  payments  in the  five 
States  were  made  to 9 suppliers,  6 percent  of the  sample.  One  supplier  alone 
received  19 percent  of the  questionable  payments.  Over  three-quarters  of 
questionable  wound  care  payments  was made  for beneficiaries  who  resided  in nursing 
homes. 
N&g  horns  h  OperationRestore tit  Stites reportsimilarmarketingpractices by 
wound care suppi%m;huwevq  in some Statesthe practices are more *pread 
Overall,  among  the  five Operation  Restore  Trust  States  there  were  not  significant 
variances  in how nursing  homes  responded  to survey questions  concerning  supplier 
marketing  practices.  However,  the  prevalence  of inducement  offers  from  suppliers 
did vary  significantly  among  the  ORT  States.  In addition,  the  degree  of influence 
some  suppliers  attempt  to have  over  the  provision  of wound  care  supplies  to nursing 
homes  differs  among  ORT  States. 
We  solicited  and  received  comments  on  our  draft  reports  from  HCFA  and  other 
concerned  organizations.  The  organizations  that  provided  us with  responses  were  the 
Health  Industry  Distributors  Association  (HIDA),  the  Health  Indust~  Manufacturers 
Association  (HIMA),  and  the  National  Association  for the  Support  of Long  Term 
Care  (NASL). 
The  NASL  made  the  only comment  that  was directed  specifically  at this report.  They 
stated  that  the  fact  that  the  five Operation  Restore  Trust  States  account  for  a high 
proportion  of the  wound  care  supplies  is only logical  since  these  are  the  States  with 
the  largest  Medicare  market.  We  agree.  The  purpose  of this report  was to provide  a 
single  document  that  would  be  useful  to the  Operation  Restore  Trust  partners  who 
are  operating  in the  five States.  This  report  is a compilation  of information  collected 
ii  for two companion  reports,  Questionable Medicare Payments for  Wound Care Supplies 
(OEI-03-94-O0790),  and Marketing of Wound Care Supplies  (OEI-03-94-00791).  The 
remaining  comments  from  HCFA  and  the  outside  organizations  and  our  responses  to 
those  comments  are  presented  in  the  companion  reports. 
... 
111  TABLE  OF  CONTENTS

PAGE 


UMMARy  . . . ...
EXE~  s 
.1

mODUmON  ................................................

.8

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

  Excessive  utilization  ofsupplies  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
.  10

  Concentration  of Medicare  allowances  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
11

  Supplier  marketing  ofwound  care  supplies  . . . . . . . . . . . . . . . . . . . . . . . . . . . 
..13

CC)MMENTS  . . . . . . .....  . . . . . . . . . . . . . . . . ..... 
APPENDI= 
-Descriptions  and  Guidelines  . . . . . . . . . . . . . . . . . . .  A-1 
k
 Wound  Care  Supplies 
.  B-1

B:  Confidence  Intervals  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c.  Questionable  Allowances  by HCPCS  and  State  . . . . . . . . . . . . . . . . . . . . . . .  C-1 
. .  D-1

D  Nursing  Home  State  Data  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  INTRODUCTION

PURPOSE 
This  report  identifies  questionable  billing  practices  and  describes  supplier  and  nursing 
home  practices  that  can  lead  to questionable  payments  under  the  Medicare  Part  B 
wound  care  benefit  in the  five States  targeted  by Operation  Restore  Trust:  California, 
Florida,  New York,  Illinois,  and  Texas. 
BACKGROUND 
Wound  care  supplies  are  fillers  or protective  covers  that  treat  openings  on the  body

caused  by surgical  procedures,  wounds,  ulcers,  or burns.  Wound  covers  are  flat

dressing  pads.  Wound  fillers  are  dressings  placed  into  open  wounds  to  eliminate  dead

space,  absorb  exudate,  or maintain  a moist  wound  surface.  The  Health  Care

Financing  Administration  (HCFA)  reimburses  for wound  care  supplies  under  the

Medicare  Part  B programs  coverage  for  durable  medical  equipment  (DME).  The

coverage  policy for these  supplies  is found  in section  2079 of the  Medicare  Carriers

Manual.  The  HCFA  contracts  four  DME  regional  carriers  (DMERCS)  to process

durable  medical  equipment  claims  including  wound  care  supplies.  The  DMERCS  issue

their  own guidelines  to clarify their  coverage  policy.

Medkare PartBAllowancesfor WoundCareSuppliks:1990-1994 
There  were  significant  changes  in wound  care  activity between  1990 and  1994. 
Medicare  Part  B allowances  were  as low as $50 million  in 1992 and  peaked  in  1993 at 
$132 million,  an increase  of 164 percent.  The  number  of beneficiaries  that  annually 
received  these  supplies  ranged  from  86,600 in 1993 to  as high as 273,300 in  1991.  As 
a result,  allowances  per  beneficiary  varied  from  $199 in 1990 to $1,526 in  1993. 
Between  1993 and  1994 the  number  of Medicare  beneficiaries  that  received  wound 
care  supplies  increased  47 percent. 
In  1994, 61 percent  of the  average  allowance  per  beneficiary  was for  specialty 
dressings.  Medicare  fee  schedule  amounts  for specialty  dressings  are  as high  as $35 
for large  hydrogel  wound  covers.  Eleven  of the  specialty  wound  care  products  are 
reimbursed  by Medicare  at over  $10.  Prior  to  1992, Medicare  reimbursed  for wound 
care  supplies  primarily  in a single kit payment.  These  kits were  a compilation  of 
wound  care  supplies  and  were  reimbursed  at  $8 each  in 1992.  Billing for kits was 
disallowed  in 1992.  However,  component  supplies  contained  in a kit can  still be  billed 
as individual  products.  Billing for kits was disallowed  in 1992.  As a result,  the  number 
of wound  care  supplies  has  increased  over  six times  from  13 million  in 1991 to  81 
million  in  1994.  The  table  on the  next  page  summarizes  surgical  dressing  activity  for 
calendar  years  1990 through  1994. 
1
 Table 1. Wound Care SupplyActivity  1990-1994 
Allowances  $53 million  $87 million  $50 million  $132 million  $98 million 
Beneficiaries  266,400  273,300  117,300  86,600  127,300 
Per  Beneficiary  $199  $317  $423  $1,526  $769 
No.  of Supplies  NIA  13 million  45 million  69 million  81 million 
TheHCFA BroadensitsCovemgePolicyfor Woundtire  Supplies 
On  March  30, 1994, HCFA  expanded  its coverage  policy for wound  care  supplies. 
The  new  policy  states  that  coverage  is ...limited  to primary  and  secondary  dressings

required  for the  treatment  of a wound  caused  by, or treated  by, a surgical  procedure

that  has  been  performed  by a physician  or other  health  care  professional.  Primary

dressings  are  therapeutic  or protective  coverings  applied  directly  to wounds  or lesions

either  on the  skin or caused  by an opening  to the  skin.  These  include  alginate,  foam,

specialty  absorptive,  hydrogel,  hydrocolloid,  and  composite  dressings.  Transparent  film

and  contact  layers  also serve  as primary  dressings.  Secondary  dressings  serve  a

therapeutic  or protective  function  and  typically  are  needed  to secure  a primary

dressing.  Items  such  as adhesive  tape,  roll gauze,  and  bandages  are  examples  of

secondary  dressings.

The PiihrMidicare CovemgePoiky WasMore Restrictive 
The  HCFA  national  policy  and  the  DMERCS  policies  prior  to March  30, 1994 were 
more  restrictive.  Stringent  requirements  were  placed  on the  type  of dressings,  length 
of treatment,  cause  of wound,  type  of provider,  and  medical  documentation.  The 
DMERCS  policy before  the  expansion  of the  national  policy  covered  only primary 
dressings  resulting  from  a surgical  procedure  for usually  no more  than  2 weeks.  This 
policy  stated  that  surgical  dressings  for closed  incisions  without  drainage  would  rarely 
be  medically  necessary  for more  than  1 week  and  when an ulcer,  traumatic  wound, 
or burn  has  had  sharp  debridement,  it will be  considered  a surgical  wound  for  no 
more  than  2 weeks  from  the  date  of debridement. 
Prior  to March  30, 1994, the  HCFA  national  policy would  allow dressings  to be 
covered  for  treatment  of wounds  that  resulted  from  sharp  debridement  (e.g.,  scalpel, 
laser)  performed  only by physician.  The  DMERC  local  policies  stated  that  dressings 
for other  types  of debridement  (e.g., mechanical,  chemical,  autolytic)  were  not 
covered.  Wound  care  suppliers  were  required  by DMERCS  to submit  a certificate  of 
medical  necessity  to  document  the  need  for the  products.  After  the  policy  change  in 
March  1994, this was no longer  required.  The  table  on the  following  page  compares 
the  wound  care  supply  policy before  and  after  March  30, 1994. 
2
 Table 2.  Comparison of Wound Care Supply Coverage Policies 
Only primary  dressings  Primary  and  secondary  dressings 
Time  limits  on medical  necessity  As long as medically  necessa~ 
II I 
Dressings  for sharp  debridement  only  Any type  of debridement 
Limited  to physician  treatments  Physician  and  non-physician  treatments 
Certificate  of Medical  Necessity  Certificate  of Medical  Necessity 
required  not  required 
Canier Romssing of Wound Care Supplk 
In June  1992, HCFAissued  afinalrule  designating  four  Durable  Medical  Equipment 
Regional  Carriers  (DMERCS)  to process  all claims  for  durable  medical  equipment, 
including  wound  care  supplies.  The  four  carriers  are  the  MetraHealth  Insurance 
Company  (DMERC  A),  AdminaStar  Federal  (DMERC  B), Palmetto  Government 
Benefits  Administrators  (DMERC  C) and  Cigna  Healthcare  (DMERC  D).  Effective 
October  1, 1993, HCFA  began  the  transition  to the  DMERC  processing  wound  care 
supply  claims.  During  1994, 56 carriers  also processed  surgical  dressing  claims  before 
the  transition  to DMERCS  was complete.  During  the  transition,  these  carriers  did not 
utilize  the  DMERC  policies;  they  carriers  used  their  own local  policies  to process 
claims. 
l%e DME Reghal  (hriem  Implementa Fee SchedideandIntrodke  New Codks 
Starting  in June  1994, reimbursements  for wound  care  supplies  were  based  on a fee 
schedule.  The  DMERCS  introduced  over  60 codes  for wound  care  products  to 
implement  the  fee  schedule.  Prior  to June,  less than  20 codes  were  used  to identify 
and  reimburse  dressings.  The  DMERCS  granted  a grace  period  for all but  two old 
codes  submitted  through  October  1, 1994.  During  the  grace  period  the  DMERC 
would  crosswalk  the  old code  to the  appropriate  new code. 
l%e DMERC3 hue  Dn@ Polity to Ckzr@ Wound Care Cinwrage 
Each  DMERC,  working  with  HCF~  developed  a policy to clarify the  coverage  of the 
wound  care  benefit.  Included  in these  guidelines  are  definitive  utilization  and  medical 
necessity  parameters.  In addition,  modifiers  to the  codes  have  been  added  to identi~ 
the  number  of wound  sites being  treated.  In January  1995, each  DMERC  solicited 
comments  on these  guidelines.  After  reviewing  the  comments,  the  DMERCS  issued 
revised  policies  to be  effective  October  1, 1995.  See  Appendix  A for  a summary  of 
the  utilization  guidelines. 
3
 This  change  was initiated  in part  as a response  to organizations  in the  wound  care 
community  that  expressed  the  need  for  clarification.  For  example,  the  Health  Industry 
Distributors  Association  in cooperation  with  the  National  Coalition  for  Wound  Care, 
the  National  Association  of Retail  Druggists,  and  the  National  Association  for  the 
Support  of Long  Term  Care  developed  consensus  recommendations  for improving  the 
Medicare  wound  care  policy.  These  changes  were  recommended  prior  to the  release 
of the  proposed  changes  in January  1995. 
l%e GeneralAccounting @ice  DircloserSimihrrAbuses 
The  General  Accounting  Office  (GAO)  issued  a final  report,  Medicare:  Excessive 
Payments for Medical  Supplies Continue Despite Improvements  (HEHS-95-171),  in 
August  1995 concerning  payment  controls  for Medicare  expenditures  of durable 
medical  equipment  with  an  emphasis  on wound  care  supplies.  The  GAO  found  a 
lack of system  wide  controls  which  led  to  abuse  in both  Part  A and  Part  B.  For 
example,  the  number  of dressings  billed  per  beneficiary  was, on average,  nearly  three 
times  higher  under  29 new wound  care  codes.  They  attribute  this  activity  to the 
absence  of a clearly  defined  policy. 
Opation  Restore tit  TargetsHealih CareAbuse in Five Stata 
Operation  Restore  Trust  (ORT)  is a health  care  anti-fraud  demonstration  project 
developed  within  the  U.S. Department  of Health  and  Human  Services  by the  Office  of 
Inspector  General,  the  Health  Care  Financing  Administration,  and  the  Administration 
on Aging.  Its aim  is to coordinate  Federal  and  State  resources  to attack  fraud  and 
abuse  in home  health  agencies,  nursing  facilities,  and  durable  medical  equipment, 
including  wound  care  supplies.  The  projects  initial  focus will be  in California,  Florida, 
New  York,  Illinois,  and  Texas. 
METHODOIX)GY 
QuestiimableBUings 
To  asses  the  nature  of questionable  billing practices,  we interviewed  DMERC  officials 
including  medical  directors  and  fraud  control  personnel.  Each  DMERC  responded  to 
a questionnaire  concerning  wound  care  supply  processing  guidelines,  the  nature  of 
questionable  billing  practices,  and  corrective  actions  taken. 
To  determine  the  extent  of questionable  billing  practices,  we analyzed  a 1 percent 
sample  of wound  care  beneficiaries.  These  beneficiaries  received  supplies  under  one 
of 85 wound  care  supply  codes  in use between  June  1994, the  start  of fee  schedule 
reimbursements,  through  February  1995.  These  claims  are  maintained  in HCFAS 
National  Claims  History  100 percent  Physician/Supplier  database.  Medicare  Part  B 
allowed  $980,270  in wound  care  supplies  for our  sample  of 1,205 beneficiaries  for  this 
9-month  period.  The  five Operation  Restore  Trust  States  accounted  for  727 
beneficiaries  and  $760,502  in Medicare  allowances.  Allowed  payments  include  the  80 
4  percent  Medicare  payment  and  the  20 percent  coinsurance  fee  billed  to the

beneficiary.

We  applied  the  proposed  DMERC  draft  guidelines  to these  claims  to identify

questionable  billing  practices.  Although  these  guidelines  were  not  inforce  during  the

review  period,  they  represent  a consensus  concerning  wound  care  policy  that  couldbe

systematically  applied  and  measured.  We  assumed  the  maximum  allowable  usage  each

month  for the  month  in which  the  supply was billed.  We  defined  a questionable

billing  practice  as that  amount  in excess of the  utilization  guideline.  We  assumed  each

type  of wound  cover  billed  represented  a wound  site.  We  reported  Medicare

allowances  above  the  tolerance  levels by type  of supply,  DMERC,  and  number  of

beneficiaries  receiving  supplies,  and  supplier.  To  determine  if a link exits among

suppliers  suspected  of abusive  billing  practices,  we reviewed  data  from  the  National

Supplier  Clearinghouse  (NSC).  Under  each  provider  identification  number,  the  NSC

database  includes  the  name  of corporate  officials,  addresses,  and  provider  aliases.

Claims  for  tape  supplies  (HCPCS  A4454  and  K0265)  were  analyzed  differently.  We

selected  101 beneficiaries  from  two groups  of a stratified  sample  of 349 beneficiaries

that  received  tape.  The  first  strata  contained  31 beneficiaries  that  received  $1,000 or

more  in tape.  The  second,  318 beneficiaries  that  received  between  $25 and  $999 in

tape.  We  selected  all 31 from  the  first strata  and  randomly  selected  70 beneficiaries

from  the  second.  This  sample  of 101 beneficiaries  represent  $73,848.13  or 52 percent

of total  allowed  dollars  in tape  claims.  The  five Operation  Restore  Trust  States

accounted  for 50 beneficiaries  and  $28,822.54  in Medicare  allowances  from  the  sample

of  101 beneficiaries.

For  each  tape  claim, we assumed  that  the  beneficia~  used  the  maximum  monthly

allowable  usage  for each  primary  and  secondary  dressing  billed  during  that  month

according  to the  proposed  DMERC  draft  guidelines.  The  secondary  dressing  was

allocated  the  same  amount  of tape  as the  primary  dressing.  Dressings  with  an

adhesive  border  were  not  allocated  tape.

We  assumed  dressings  less than  or equal  to  16 square  inches  to be  4 inch by 4 inch.

We  assumed  a 6 inch by 8 inch  size for dressing  between  16 and  48 square  inches  and

8 inches  by 8 inches  for dressings  greater  than  or equal  to 48 square  inches.  We

allocated  tsvo inches  extra  of tape  for  each  side.  Therefore,  a 4 inch by 4 inch

dressing  was allocated  24 inches  of 1 inch tape.  A 6 inch by 8 inch  dressing  was

allocated  36 inches  and  a 8 inch by 8 inch  dressing,  40 inches.  We  applied  the  current

fee  schedule  price  of $0.12 per  18 square  inches  to the  tape  allocated.  Each  4 inch by

4 inch  dressing  used  $0.16 in tape.  A 6 inch by 8 inch  dressing  used  $0.24 in tape,

$0.27 for  a 8 inch by 8 inch  dressing.

To  quantify  the  potential  impact  of questionable  billing practices,  we projected  our

findings,  by multiplying  sample  results,  i.e., Medicare  allowances  above  the  proposed

DMERC  guidelines,  by 100.  Confidence  internals  for our  projections  are  presented  in

Appendix  B.

5  Ntig  ~07?lt3  Swvey 
To  determine  how suppliers  market  wound  care  supplies  and  how nursing  homes 
handle  the  provision  of these  supplies,  we selected  a stratified  random  sample  of 420 
skilled  nursing  facilities  and  nursing  homes  from  the  Health  Care  Financing 
Administrations  Online  Survey  Certification  and  Reporting  (OSCAR)  system.  The 
system  contains  every  nursing  home  that  is certified  to receive  Medicare  or Medicaid 
funds.  We  decided  to  sample  nursing  homes  from  the  OSCAR  system  that  had  a total 
size of 60 beds  or more.  This  gave us a universe  of 12,878 nursing  homes  from  which 
we selected  our  sample. 
We  selected  a stratified  sample  so that  we could  provide  more  focused  information  on 
five States:  California,  Florida,  Illinois,  New York,  and  Texas.  These  States  are 
curiently  being  targeted  by Operation  Restore  Trust.  We  stratified  our  sample  into  six 
groups  including  the  five States  and  all other  remaining  States.  We  sampled  a total  of 
420 nursing  homes;  the  number  of nursing  homes  from  each  stratum  is shown  in the 
table  below. 
Strata  Universe  Sample  Responding 
Universe 
California  931  60  636 
Florida  565  60  414 
Illinois  700  60  537 
New  York  584  60  457 
Texas  964  60  723 
Other  States  9,134  120  7,003 
Total  12,878  420  9,770 
We  sent  identical  questionnaires  to the  administrators  of the  420 nursing  homes. 
Surveys were  returned  by 315 nursing  homes  giving us an  overall  response  rate  of 75 
percent.  We  chose  to project  responses  only to the  responding  universe  and  not  to 
the  total  universe  of 12,878 nursing  homes.  Responses  from  the  315 nursing  homes 
were  weighted  by stratum  and  projected  only to the  responding  universe  of 9,770 
nursing  homes.  The  responding  universe  for each  stratum  in included  in the  table 
above. 
In order  to accurately  project  responses  to the  total  universe,  we would  have  had  to 
perform  an  analysis  of non-respondents  to evaluate  the  characteristics  of nursing 
homes  who  chose  not  to  respond.  Because  we knew very little  about  the  non-
responding  nursing  homes,  we decided  to use  the  more  conservative  responding 
universe. 
6
 For  comparison  purposes,  data  from  the  each  of the  fives States  is presented  along 
with  data  from  the  remaining  45 States  in Appendix  D. 
Reprt  l%xentation 
This  report  is one  of three  reports  concerning  Medicare  payments  for wound  care 
supplies.  The  second  report,  Questionable Medicare Payments for  Wound Care Supplies 
(OEL03-94-00790)  identifies  questionable  billing  practices  for wound  care  supplies 
under  Medicare  Part  B between  June  1994 and  February  1995.  A third  report 
Marketing of Wound Care Supplies (OEI-03-94-00791)  describes  supplier  and  nursing 
home  practices  that  can  lead  to questionable  payments  and  examines  issues  concerning 
Medicare  beneficiaries  use  of wound  care  supplies  nationally. 
This  inspection  was conducted  in accordance  with the  Quali~  Standards for Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency  and  is part  of Operation 
Restore  Trust. 
7
 FINDINGS

OVER  $22 MILLION OF $65 WON  IN QUESTIONABLE  PAYMENTS FOR 
WOUND  CARE SUPPLIESBETWEEN JUNE 1994AND FEBRUARY  1995WAS 
FOUND  IN THE FIVE OPERATION  RESTORE  TRUST STATES. 
The  five States  targeted  by Operation  Restore  Trust,  California,  Florida,  New  York, 
Illinois,  and  Texas  accounted  for  $22 million  in Medicare  allowances  for wound  care 
supplies  that  exceeded  utilization  guidelines  between  June  1994 and  February  1995. 
For  all States,  $65 million  of the  $98 million  in Medicare  Part  B allowances  for wound 
care  supplies  exceeded  the  proposed  DMERC  guidelines. 
Quatiouble  billingpmcti=  found in 62pemnt  of Medicareallowancesin O~ation 
Restore llu.st Stakx 
The  $22 million  in questionable  payments  in California,  Florida,  New York,  Illinois, 
and  Texas  represent  62 percent  of the  $36 million  in total  wound  care  allowance  for 
those  States.  Non-tape  supplies  account  for over  $18 million  of the  questioned 
payments,  tape  approached  $4 million.  These  States  had  39,200 beneficiaries  that 
received  wound  care  supplies.  Excess  utilization  was found  in 26,200 beneficiaries  that 
received  non-tape  supplies.  The  table  below  summarizes  the  wound  care  activity  for 
the  five Operation  Restore  Trust  States  between  June  1994 and  February  1995. 
Table 3.  Wound Care Activity Summary-5  Operation Restore Trust States 
Submitted  $76,050,200  72,700  $1,046  36,313,600 
Allowed  $35,640,150  39,200  $910  26,969,200 
Total  Questioned  $22,250,630  N/A  N/A  N/A 
Questioned  - Non-Tape  $18,552,330  26,200  $708  12,938,400 
Questioned  - Tape  $3,698,300  N/A  N/A  N/A 
Significantlyhighercosts per benejichq  wasfound ti Illbwik. 
The submitted,  allowed,  and  questioned  wound  care  amounts  per  beneficiary  were 
significantly  higher  in Illinois  than  the  other  Operation  Restore  Trust  States.  The 
wound  care  claims  that  were  submitted  for 68 Illinois beneficiaries  in our  sample 
averaged  $2,421.  The  next  highest  average  in the  ORT  States  was found  in New  York 
at $1,612, no other  ORT  State  exceeded  $790.  The  Medicare  allowed  charges  for 50 
Illinois beneficiaries  averaged  $1,515.  California  followed  at $962 per  beneficiary. 
Questionable  payments  were  found  in 33 Illinois beneficiaries  that  received  non-tape 
8 
.  supplies.  These  payments  averaged  $1,176, almost  double  the  $690 average  of 
However,  one  Illinois beneficiary  received  questionable 
California  beneficiaries. 
papents  of$21,770,  which  represented  12percent  of the  ORT  total.  Questionable 
pa~ents  fortheother  32 Illinois beneficiaries  averaged  $532.  Thetable  below 
summarizes  the  wound  care  activity from  the  sample  of beneficiaries  in each  State. 
Submitted  and  allowed  totals  include  tape,  questioned  amounts  are  for non-tape 
supplies  only. 
Table 4.  Wound Care Activity- Each Operation Restore TrustState 
164,597  $2,421 
c.. 
$75,765  $1,515 
mlu w Uu  I  I  17,189 $38,811  $1,176 
Questioned  - Non-Tape  I  33 
California 
61,030  $141,612  $553 
256 
Submitted 
79  46,731  $75,993  $962 
-A1lln mn=d/-
v. 
Gn-Tape  63  20,833  $43,467  $690 
l==Questioned  - I
New York 
180  151,335  $290,176  $1,612 
Submitted

128  116,953  $119,867  $936 
Allowed

$629 
62,782  $59,740 
Questioned  - Non-Tape
 95 
Florida 
 
1=
109  41,868  $86,152  $790 
SL ubmitted
  
u  IAluu -wed 67  36,602    $56,241  $839 
~  M Non-Tape  48  15,859    $30,712  $640 
UG3  LIULIW- -l
!, Texas 
,,  ,, 
4 114  41,622  $77,965  $684 
Submitted 
68  26,143  $28,736  $423 
AIln.xh=d
mlu  w .- , 
23  12,721  $12,793  $556 
Questioned  - Non-Tape 
9
 QUESTIONABLE  WOUND  CARE PAYMENTS IN ORT STATES ARE 
CONCENTRATED  BY PRODUCI,  SUPPLIER  AND PLACE OF SERVICE 
The  excessive  payments  for wound  care  products  in California,  Florida,  New  York, 
Illinois,  and  Texas  was concentrated  in a small  number  of products  and  suppliers.  In 
addition  most  of these  payments  were  made  for beneficiaries  that  resided  in Skilled 
Nursing  or Nursing  Facilities. 
Hjdiogel woundcarep&ts  accountfor 41pement of thequekmable  Medicare 
alibwancesfor non-tape supphk 
In the  five Operation  Restore  Trust  States,  questionable  payments  for  hydrogel  wound 
care  products  accounted  for  41 percent  of the  non-tape  supplies  that  exceeded 
utilization  guidelines.  Of the  $185,523  in questionable  non-tape  payments  in our 
sample,  $76,277 was made  for hydrogel  products.  We  identified  $44,356 in 
questionable  payments  for hydrogel  wound  filler  alone.  The  data  in Appendix  C 
provides  the  Medicare  allowances  in our  sample  that  exceeded  the  proposed  DMERC 
guidelines  for  each  wound  care  product,  not  including  tape. 
Abnost halfof the excessivepaymentsh  thejive Statesweremade to 9supph%, 6 
percent of the sample.  One wpplier aknw 19pement of the questionablepayments. 
Nine  suppliers  received  49 percent  of the  non-tape  payments  for supplies  that  exceed 
utilization  guidelines.  They  represent  6 percent  of the  155 suppliers  who  provided 
wound  care  supplies  in California,  Florida,  New York,  Illinois,  and  Texas.  The 
individual  States  show a similar  concentration.  In Illinois,  one  supplier  received  57 
percent  of the  questionable  payments,  two others  received  a total  of 19 percent,  for  an 
overall  total  of 76 percent.  Two suppliers  in Texas  received  approximately  half  of the 
questionable  non-tape  payments  identified  in that  State.  In California  and  Florida,  it 
was three  suppliers,  in New  York  it was four. 
One  of these  suppliers  appeared  at the  top  in both  California  and  Illinois  and  received 
19 percent  of all questionable  payments  in the  five States.  Another  supplier  appeared 
at the  top  in New York  and  Texas  and  received  3 percent  of all questionable 
payments  in the  five States 
Over three-quartemof questinuble  woundcarepqments  wasrnadkfor 54 penxmt  of 
benejkiaries who residedSkilkdNursingor N&g  Facilitks. 
Over  77 percent  of the  excessive  Medicare  allowed  payments  for non-tape  supplies 
was made  for beneficiaries  that  resided  in skilled  nursing  or nursing  facilities.  The 
beneficiaries  in these  locations  accounted  for 54 percent  of all beneficiaries  in 
California,  Florida,  New York,  Illinois,  and  Texas.  The  remaining  23 percent  of excess 
payments  was made  for  the  46 percent  of the  beneficiaries  that  resided  at home  or a 
custodial  care  facility.  The  table  on the  following  page  shows the  excessive  payments 
10
 for non-tape  supplies  by place  of service.  Nine  beneficiaries  appear  in more than one 
place. 
Table 5.  ExcessivePaymentsfor Non-Tape Wound Suppliesby Place of Service 
Skilled  Nursing  Facility  120  $125,597 
Home  123  $38,443 
Nursing  Facility  27  $17,385 
Custodial  Care  Facility  1  $4,098 
NURSING  HOMES IN OPERATION  RESTORE TRUST STATES REPORT 
smALAR  MARKETING  PRACIICES  BY WOUND  CARE SUPPLIER% 
HOWEVER  IN SOME STATES THE PRACTICES ARE MORE  WIDESPREAD. 
Overall,  among  the  five Operation  Restore  Trust  States  there  were  not  significant 
variances  in how nursing  homes  responded  to survey  questions  concerning  supplier 
marketing  practices.  This was true  when  comparing  both  the  ORT  States  to  each 
other  and  to the  rest  of the  States  in the  nation.  However,  there  were  several  supplier 
marketing  practices  where  certain  ORT  States  reported  significantly  different  levels  of 
occurrence.  A copy  of the  survey instrument  with individual  State  responses  for  each 
question  is provided  in Appendix  D. 
l%e prevalence of indkement  offeis from suppiiensvariedsignificantlyamong the ORT 
States. 
While  23 percent  of Florida  nursing  homes  and  22 percent  of Texas  nursing  homes

reported  having  been  offered  inducements  such  as free  gift or supplies  from  wound

care  suppliers,  only 4 percent  of New York  nursing  homes  report  such inducements.

I.-ESSthan  one-tenth  of Illinois  nursing  homes  (7 percent)  reported  supplier

inducement  attempts.  Californias  nursing  homes  reported  inducements  at  a rate  of 15

percent  which was similar  to the  13 percent  average  of all other  States.

llw digree of in.e  some supphknrattemptto have over theprovkion of wound care 
suppliesto numinghomes ~izw  among ORT States. 
Among  the  ORT  States,  nursing  homes  differ  on whether  it is their  staff  or  the 
supplier  representative  that  decides  the  number  of wound  care  supplies  to be 
delivered  in a given month.  Only 7 percent  of California  nursing  homes  had  suppliers 
making  this  determination,  while  more  than  one-third  of nursing  homes  in New  York 
(34 percent)  had  suppliers  performing  this task.  Eleven  percent  of nursing  homes  in 
Florida  had  suppliers  determining  the  amount  of supplies  delivered  in a month. 
While,  Illinois  and  Texas  had  24 and  22 percent  respectively.  Similar  to  Illinois  and 
11
 Texas,  24 percent of allother Statesreported thatsuppliersdeterminedthe numberof 
supplies provided monthly. 
Nursing  homes  in the  ORT  States  reported  statistically  significant  differences  in

suppliers  provision  of prescription  forms  to be filled  out  by the  nursing  home  or

patients  physician.  New York  facilities  reported  a high  of 34 percent  of suppliers

providing  these  forms.  In addition,  nursing  homes  in New  York  appear  more  likely to

also  have  suppliers  fill out  the  prescription  form  and  present  it for the  physicians

signature  than  other  States.  All of the  ORT  States  reported  higher  percentages  for

supplier  provision  of prescription  forms  than  the  8 percent  average  reported  by all

other  States.

The  ORT  States  also  differ  in the  amount  of access  suppliers  request  to patient

medical  records.  Almost  half  of the  nursing  homes  in New York  (47 percent)

reported  that  supplier  representatives  have  requested  to review  patient  medical

records.  This  percentage  was more  than  double  the  percentage  of nursing  homes

reporting  this situation  in non-ORT  States  (20 percent).  The  next  highest  ORT  State

was Florida  with  16 percent  and  Illinois,  California,  and  Texas  with  13, 12, and  11

percent.

12
 COMMENTS

We  solicited  and  received  comments  on  our  draft  reports  from  HCFA  and  other 
concerned  organizations.  The  organizations  that  provided  us with  responses  were  the 
Health  Industry  Distributors  Association  (HIDA),  the  Health  Industry  Manufacturers 
Association  (HIMA),  and  the  National  Association  for the  Support  of Long  Term 
Care  (NASL). 
The  NASL  made  the  only comment  that  was directed  specifically  at this report.  They 
stated  that  the  fact  that  the  five Operation  Restore  Trust  States  account  for  a high 
proportion  of the  wound  care  supplies  is only logical  since  these  are  the  States  with 
the  largest  Medicare  market.  We  agree.  The  purpose  of this report  was to provide  a 
single  document  that  would  be  useful  to the  Operation  Restore  Trust  partners  who 
are  operating  in the  five States.  This  report  is a compilation  of information  collected 
for  two companion  reports,  Questionable  Medicare Payments for  Wound Care Supplies 
(OE1-03-94-00790),  and Marketing of Wound Care Supplies  (OEI-03-94-00791).  The 
remaining  comments  from  HCFA  and  the  outside  organizations  and  our  responses  to 
those  comments  are  presented  in the  companion  reports. 
13
 APPENDIX  A

WOUND  CARE  SUPPLY UTILIZATION  GUIDELIN= 
OCTOBER  1, 1995 
HCPCS  WOUNDC4RE PRODUCX  STANDARD 
K0196  Alginatedressingwoundcover,withoutadheaive,16 sq. in. or less  llday

K0197  Alginatedressingwoundcover,withoutadhesive,>=  16 sq. in. <= 48 sq. in.  llday

K0198  Alginatedressingwoundcover,withoutadhesive,morethan48sq.in.  llday

K0199  Alginatedressingwoundfiller,per 6 inches  21day

K0203  Compositedressingwoundcover,withadhesive,16sq.in.or less  3iweek

K0204  compositedressingwoundcover,withadhesive,>= 16sq.in.<= 48sq.in.  3/week

K0205  Compositedressingwoundcover,withadhesive,morethan48sq.hi.  3/week

K0206  Contactlayer,16sq.in.orless  Mveek

K0207  Contactlayer,>=  16sq.in. <= 48sq.in.  l/week

K0208  Contactlayer,more than 48 sq. in.  liweek

K0209  Foamdressingwoundcover,withoutadhesive,16sq.in.or less  3fweek

KO21O Foamdressingwoundcover,withoutadhesive,>= 16sq.in.c=  48sq.ln- 3/week

K0211  Foamdressingwoundcover,withoutadhesive,morethan48sq.in.  3iweek

K0212  Foamdressingwoundcover,withadhesive,16sq.in.or less  3fweek

K0213  Foamdressingwoundcover,withadhesive,>= 16sq.in. c=  48 sq.in.  3/week

K0214  Foamdressingwoundcover,withadhesive,morethan48sq.in.  31week

K0215  Foam dressingwoundfiller,per gram  llday

K0216  Gauzenon-impregnatedw,ithoutadhesive,16sq.in.or less  31day

K0217  Gauzenon-impregnatedw,ithoutadhesive,>=  16sq.in.<= 48sq.in.  31day

K0218  Gauzenon-impregnatedw,ithoutadhesive,morethan48sq.in.  31day

K0219  Gauzenon-impregnatedw,ithadhesive,16sq.in.orless  lfday

K0220  Gauzenon-impregnatedw,ithadhesive,>= 16sq.in.<= 48sq.in.  llday

K0221  Gauzenon-impregnatedw, ithadhesive,morethan48sq.in.  llday

K0222  Gauzeimpregnatedw, ithoutadhesive,16sq.in.or less  ltday

K0223  Gauzeimpregnatedw, ithoutadhesive,>= 16sq.in. <= 48sq.in.  llday

K0224  Gauzeimpregnatedw, ithoutadhesive,more than 48 sq. in.  I/day

K0228  Gauzeimpregnated,withoutadhesive,16sq.in.or less  I/day

K0229  Gauzeimpregnatedw, ithoutadhesive,>= 16sq.in. <= 48sq.in.  Iiday

K0230  Gauzeimpregnatedw, ithoutadhesive,morethan48sq.in.  ljday

K0263  Gauzeelastic,alltypes,per linearyard  sameas prima~

K0264  Gauzenonelastic,perlinearyard  sameasprimary

K0266  Gauzeimpregnated,anywidth,per linearyard  sameas primary

K0234  Hydrocolloiddressingwoundcover,withoutadhesive,16sq.in.or less  3iweek

K0235  Hydrocolloiddressingwoundcover,withoutadhesive,>=  16sq.in. <= 48sq.in.  3/week

K0236  Hydroccdloiddr
essingwoundcover,withoutadhesive,morethan48sq.in.  3/week 
K0237  Hydrocolloiddressingwoundcover,withadhesive,16sq.in.orless  3/tmek 
K0238  Hydrocolloiddressingwoundcover,withadhesive,>= 16sq.in.<= 48sq.in.  3Jweek 
K0239  Hydrocolloiddressingwoundcover,withadhesive,morethan48sq.in.  3Aveek 
K0240  Hydrocolloiddressingwoundfiller,paste,per fluidounce  31week 
K0241  Hydrocolloiddressingwoundfiller,dryform,per gram  3/week 
A-1
 HCPCS  WOUND CARE PRODU~  STANDARD 
K0242  Hydrogeldressingwoundcover,withoutadhesive,16sq.in.or less
 llday 
K0243  Hydrogeldressingwoundcover,withoutadhesive,>= 16sq.in. <= 48sq.in.
 l/day 
K0244  Hydrogeldressingwoundcover,withoutadhesive,morethan48sq.in.
 l/day 
K0245  Hydrogeldressingwoundcover,withoutadhesive,16sq.in.or less
 3fweek 
K0246  Hydrogeldressingwoundcover,withoutadhesive,>= 16sq.in.<= 4Ssq.in.
 3tweetr 
K0247  Hydrogeldressingwoundcover,withoutadhesive,more than 48 sq. in.
 3/%wek 
KOX8  Hydrogeldressingwoundtiller,gel,per fluid ounce
 3/month 
K0249  HydrogeI dressing wound filler, dry form, per gram
 3/month 
K0251  Specialtyabsorptivedressingwoundcover, 
without adhesive, 16 sq. in. or less  I/day 
K0252  Specialtyabsorptivedressingwound cover, 
without adhesive, >=  16 sq. in c=  48 sq. in.  I/day 
K0253  Specialtyabsorptivedressingwoundcover, 
without adheaive, more than 48 sq. in.  I/day 
K0254  Specialtyabsorptivedressingwoundcover, 
with adhesive, 16 sq. in. or less  l/every other day 
K0255  Specialtyabsorptivedressingwoundcover, 
with adhesive, >=  16 sq. in <=  48 sq. in.  I/every other day 
K0256  Specialtyabsorptivedressingwoundcover, 
with adhesive, more than 48 sq. in.  Vevery other day 
K0257  Transparent film, 16 sq. in. or less, each dressing
 3/week 
K0258  Transparent film, > = 16 sq. in. <=  48 sq. in.
 3hveek 
K0259  Transparent film, more than 48 sq. in.
 3heek 
K0154  Wound pouch, each
 3/week 
K0261  Wound filler, not elsewhere classified,gel/paste, per fluid ounce
 I/day 
K0262  Wound filler, not elsewhere classified,dry form, per gram
 llday 
A4460  Elastic bandage, per roll
 ltweek 
K0265  Tape, all types, per 18 sq. in.
 per wound cover 
A4454  Tape, all types, all sizes
 per wound cover 
A-2
 APPENDIX  B

coI$n3m.NcE  INTERVALS 
Wereported  ourprojected  totals  by multiplying  100 bythepoint  estimates  in our 
samples.  The  point  estimates  represent  the  total  allowance,  number  of supplies,  or 
number  of beneficiaries.  The  tables  below  include  confidence  internal  columns.  The 
number  provided  in this column  is the  semi-width  of the  confidence  interval  for  each 
of the  projected  totals.  The  semi-width  is the  standard  error  of the  projection 
multiplied  by 1.96 when  computing  confidence  intervals  at the  95 percent  level.  The 
semi-width  added  to or subtracted  from  the  estimated  mean  or total  (projection) 
provides  a 95 percent  confidence  interval.  The  table  title  numbers  below  correspond 
with  the  table  numbers  in the  report. 
Table 1. Wound Cam Supply Activity  1990-1994 
Table3.  Wound lMe  Activity Summmy-50puation  RestweMst  States 
+/-$288  $1,046  +/-2,075,430  36,313,600 
+/-$138  $910  +/-5,925,809  26,969,200 
IVA  N/A  N/A  NIA 
+/-$204  $708  +/-3,263,443  12,938,400 
NIA  NIA  N/A  NJA 
B-1
 APPENDIX  C

MEDICARE PART B NON-TAPE ALLOWANCES THAT EXCEEDED 
PROPOSED  DMERC UTILIZATION  GUIDELINES 
Alginate Dressings 
K0150  $0  $0  $0  $0  $0  $0 
KOl%/KO150KB  $0  $1,386  $1,676  $292  $0  $3,354 
K0197K0150KC  $0  .$0  $0  $0  $0  $0 
KO198/KO150KD  $0  $0  $0  $0  $0  $0 
K0199  $4,747  $0  $638  $0  $0  $2,385 
,..  ,,:..,......:...,.,, ..  ,,.,.,,. . .. ..  .; .,.  .... ...  .:  :..  . ., .:. . ......  .  .. ,.,.  . 
6;&:-$i~&ii:$4&$  :.;;:;:;;;:;:.::  :;:,...:411%7;;:.;.:; :$j@&:: :,. ;.:~~,qlf;.:, ;:.,:: ,@z; :.:  ?,+J:.: ,  ,,..$5,F% 
Foam Dressings  I 
K0151  $0  $0  $0  $0  $0  $0 
K02QWK0151KB  $1,040  $3,979  $6,628  $2,507  $96  $14,250 
K0210/KO151KC  $0  $1,136  $766  $747  $511  $3,160 
K0211/KO151KD  $3,150  $0  $133  $929  $0  $4,212 
K0212  $1,920  $244  $1,644  $0  $245  $4,053 
K0213  $0  $636  $0  $0  $0  $636 
K0214  $0  $0  $0  $0  $0  $0 
K0215  $0  $0  $0  $0  $0  $0 
c-1  Gauze 
A4200  $59  $0  $403  $57  $147  $666 
A4202  $0  $0  $0  $0  $0  $0 
A4203  $0  $0  $0  $0  $0  $0 
K0216/A4200KB  $918  .$752  $4,316  $919  $869  $7,774 
K0217/A4200KC  $150  $891  $354  $1,880  $1,309  .$4,584 
K02181A4200KD  $6,215  $70  $1,456  $6,246  $0  $13,987 
K0219  $0  $0  $0  $0  $0  $0 
K0220  $0  $0  $20  $0  $0  $20 
K0221  $0  $0  $0  $0  $0  $0 
K0222  $59  $707  $741  $325  $0  $1,832 
K0223  $519  $380  $260  $0  $0  $1,159 
K0224  $0  $0  $0  $0  $0  $0 
K0228  $0  $1,649  $0  $0  $0  $1,649 
K0229  $489  $517  $2,073  $5%  $423  $4,098 
K0230  $0  $0  $0  $0  $0  $0 
K0263/A4202KF  $0  $0  $0  $0  $0  $0 
K02WA4203KF  $0  $0  $0  $0  $0  $0 
K0266  $0  $0  $0  $0  $0  $0 
,...: ;, ,,.:..:... :. .. ,,.,.., .,,:. .:,:..,,..:..:..,. : 
+..Y...<. ...$ .s.w ..z .  ... . .:,:,x,,M  w@.. :. ..........:  . .. 
Hydrocolloid Dressing 
A4204  $340  $680  $1,535  $0  $13  $2,568 
K0149  $74  $0  $0 $0 $0  $74 
K0234/KO149KB  $99  $0  $82  $190  $200  $571 
Ko235/Ko149Kc  $362  $398  $21  $0  $0  $781 
K02WK0149KD  $0  $0  $0 $0 $0  $0 
K0237  $36  $0  $197  $0  $0  $233 
K0238  $0  $52  $0  $611  $0  $663 
K0239  $0  $0  $0 $0 $0  $0 
K0240  $0  $0  $0 $0 $0  $0 
K0241  $0  $0  $0 $0 $0  $0 
:kid  - Mwii&iiiidii+iiiiti  ::  :  : .    kill: :.; :$1:1% ;   &,835; : :;ml  i  ;;RW1$;  :::~~i~~~ : 
c-2  .-..-.  t- 2 
I  ......  .  .. 
Hydrogel Dressings 
A4205
 $319  $0  $796  $637  $372  $2,124 
K0148
 $0  $0  $0  $0  $0  $0 
K0242/KO148KB
 $1,905  $292  $1,748  $250  $544  $4,739 
K0243/KO148KC
 $2,963  $178  $5,649  $0  $269  $9,059 
K02JWK0148KD
 $2,057  $0  $1,063  $11,388  $0  $14,508 
K0245
 $0  $0  $39  $0  $0  $39 
KOW6
 $0  $94  $1,174  $0  $184  $1,452 
K0247
 $0  $0  $0  $0  $0  $0 
K0248/KO148KE
 $11,405  $12,979  $13,684  $2,528  $3,760  $44,356 
K0249
 $0  $0  $0  $0  $0  $0 
Specialty AbsorptiveDressings 
K0251  $0  $30  $258  $0  $0  $% 
K0252  $60  $140  $1,165  $1,466  $194  $3,025 
K0253  $2,128  $86  $389  $1,798  $1,902  $6,303 
K0254  $240  $107  $0  $0  $0  $347 
K0255  $0  $191  $0  $0  $0  $191 
K0256  $0  $0  $0  $0  $0  $0 
!ioti-i@cial&:*ti*  :ti*j;&i:  :::..~,,. .$*W,,,.:,  ,,.:$ 5.,$ +.,:,,{,.:,.;  096.. ..:,$l.b ,js$
TransparentFilm 
A4190  $12  $0  $79  $174  $19  $M 
Ko257/A4190KB  $39  $8  $126  $0  $33  $206 
K0258/A4190KC  $1,952  $230  $1,437  $.3,454  $360  $7,433 
Ko259/A4190KD  $69  $0  $0  $0  $0  $69 
Other Supplies 
I  1 1 I  I  1 
A4323 Saline Solution  $2,828  $2,107  $7,166  $1,237  $1,346  $14,684 
I  1  f  I 
A4460 Elastic bandage  $43  $0  $236  $0  $0  $279 
I  ,  1  ! 
c-3  APPENDIX  D

NURSING  HOME  STATE  DATA 
Each  nursing  home  inoursample  wasasked  tocomplete  a48questionsumey.  The 
questions  for  the  survey were  developed  by reviewing  information  on wound  care 
supplies  produced  by HCF~  the  Durable  Medical  Equipment  Regional  Carriers, 
wound  care  suppliers,  and  professional  organizations. 
For  most  questions,  we report  the  percentage  of nursing  home  responses  to  the 
question  and  the  projected  number  of responses  by the  each  of the  five States.  The 
percentages  have  been  rounded  to the  nearest  whole  number  and  therefore  will not 
always add  up  to  exactly  100 percent.  The  projected  numbers  have  been  rounded  and 
will therefore  not  always add  up to exactly  9,770 nursing  homes.  In addition,  for 
several  questions  respondents  selected  more  than  one  answer.  These  questions  are 
identified  by an  asterisk  in the  sample  survey instrument  that  follows.  In the  several 
questions  where  respondents  were  asked  to provide  numerical  data  (e.g., number  of 
beds  or percentage  of patients  receiving  incontinence  supplies),  an  average  number  or 
percentage  is provided. 
We  also  report  the  semi-width  for each  of the  response  percentages  at the  95 percent 
confidence  level.  The  semi-width  is the  standard  error  of the  projection  multiplied  by 
1.96.  The  semi-width  added  or subtracted  to the  percentage  provides  a 95 percent 
confidence  internal.  The  range  of the  95 percent  confidence  interval  is presented  in 
the  table  following  each  question. 
Under  each  question,  a table  is presented  that  breaks  down  each  response  by State. 
For  each  State,  the  first number  provided  is the  percentage  responding,  the  second 
number  is the  semi-width,  and  the  third  number  is the  projected  number  of nursing 
homes. 
D-1
 SURGICAL  DRESSINGS  AND  WOUND  CARE  SUPPLIES 
NURSING  FACILITY  SURVEY 
This  sumey  is being  conducted  by the  Office  of Evaluation  and  Inspections  within  the 
U.S.  Department  of Health  and  Human  Services  Office  of Inspector  General.  We 
are  currently  reviewing  Medicares  payments  for surgical  dressings  and  wound  care 
supplies.  We  are  also  interested  in learning  about  equipment  suppliers  marketing 
practices  for wound  care  supplies.  When  we refer  to wound  care  supplies,  we mean 
supplies  such  as gauze,  tape,  specialty  dressings,  wound  pouches,  etc. that  are  used  in 
the  treatment  of surgical  openings  or debrided  wounds. 
Our  review  is focusing  on Medicare  Part  B payment  of wound  supplies.  Please  keep 
this in mind  when  completing  this  survey.  We  are  not  at this time  interested  in wound 
care  supplies  or surgical  dressings  that  are  included  in Medicare  Part  A cost  reports. 
All information  provided  will be  kept  confidential.  All data  will be  reported  out  in the 
~me~ate  and  the  names  of nursing  facilities  will never  be  identified  to the  Public.  If 
you  have  any questions  about  this survey,  please  call Linda  Ragone  at  1-800-531-9562. 
Pleasereturnthissurveyby March 27, 1995in the enclosed self-addressed,pre-paid 
envelope or if you prefer you can  fax it to us at  (215) 596-6987. We appreciate your 
cooperation and assistance. 
Pleaseprintthefolknvinginforrnution(@wire kiitas thereqxmdentthepemon who 
answemthe surveyquiwions): 
RESPONDENT: 
JOB  TITLE: 
NURSING  FACILITY: 
ADDRESS: 
TELEPHONE: 
D-2
 GeneralInformation 
1.  How does Medicare categorize your facility? 
Skilled Nursing Facility  76  70  43  89  22  33 
*13.1  *13.5  *14.3  *8.9  *12.1  *9.6 
483  290  231  407  159  2311 
Nursing Facility  2  0  26  6  27  17 
*4.3  *0.O  *12.7  *6.8  *13.O  *7.7 
13  0  140  27  195  1191 
Both Skilled Nursing  22  25  15  2  44  50 
Facility and Nursing  *12.7  *12.8  *1O.3  *4.O  *14.5  *1O.2 
Facility  140  104  81  9  318  3502 
Other (please speci~)  o  0  15  2  4  0 
+0.0  *0.O  *10.3  *4.O  *5.7  *0.O 
o  0 81 9 29  0 
No Response  o 5 0 0 2  0 
too  *6.4  *0.O  *0.O  *4.1  *0.O 
o 21 0  0 14 0 
2.  How many beds does your nursing facility contain? 
D-3
 4.  What percentage of your population is eligible for Medicare Part B Coverage? 
5.	 What percentage of your current patient population receive surgical dressings or wound care 
supplies (e.g. gauze, hydrogel or alginate dressings, wound pouches)? 
6.	 Are any of the surgical dressings or wound care supplies used for patients in your nursing 
facility billed to Medieare Part-B? 
Yes  54 50 48 57 49  57 
*15.3  *14.8  *14.4  *14.2  *14.6  *10.1 
343  207  258  260  354  3992 
I 
No  44  45  48  38  49  38 
*15.2  *14.7  *14.4  *13.9  *14.6  *9.9 
280  186  258  174  354  2661 
5  4  4  2  5 
~6.4  *5.7  *5.6  *4.1  *4.5 
+  21  21  18  14 350 
D-4
 7.	 Does your nursing facility directly bill Medicare Part B for wound care supplies or do you have 
at least one external supplier who bills Medicare Part B directly for these supplies? 
Nursing Facility is sole  49  23  20  4  27  33 
supplier  *15.3  ~12.4  +11.6  *5.6  *13.O  *9.6 
312  95  107  18  195  2311 
At least one external  37  36  48  70  40  45 
supplier  *14.8  *14.2  *14.4  *13.1  *14.3  *1O.2 
235  149  258  320  289  3151 
Other (please specify)  10  23  24  23  24  18 
*9.2  *12.4  ~12.3  *12.O  *12.5  *7.9 
64  95  129  105  174  1261 
No Response  5  18  9  2  9  4 
*6.7  *11.4  *8.3  *4.O  *8.4  *4.O 
32  75  48  9  65  280 
8.	 Do you have a wound care supplier that provides wound care products only to the 
Medicare-eligible patients in your facility? 
.,,.,.. ...:, ..
,..::.:.,::,,; ..  ., 
Yes  20  18  22  40  31  17 
*12.2  *11.4  *12.O  *14.O  *13.5  k7.7 
127  75  118  183  224  1191 
No  78  77  70  57  67  79 
t12.7  *12.4  *13.2  *14.2  *13.7  *8.3 
496  319  376  260  484  5532 
No Response  2  5  9  2  2  3 
*4.3  *6.4  58.3  *4.O  *4.1  *3.5 
13  21  48  9  14  210 
D-5  9.  How did your facility become aware of the suppliers you use? 
Through supplier  10  14  9  4  2  22 
advertisements  *9.2  *10.3  *8.3  *5.6  *4.1  k8.5 
64  58  48  18  14 1541 
Through supplier direct  5  9  4  2  2  8 
mail marketing  *6.7  *8.5  *5.7  *4.O  k4.1  *5.5 
32  37  21  9  14 560 
Through supplier  63  41  54  74  36  67 
representative/salesperson  *14.8  *14.5  *14.4  *12.5  *14.O  *9.6 
visit  401  170  290  338  260  4692 
Other (please speci@)  37  39  39  23  40  36 
*14.8  *14.4  *14.1  *12.O  *14.3  *9.8 
235  161  209  105  289  2521 
No Response  7  20  13  4  27  4 
*7.8  +11.8  *9.7  *5.6  *13.O  *4.O 
45  83  70  18  195 280 
~more than one answer was selected by some respondents 
D-6
 Use of Wound Care SuPPliea 
10.  Who initially identifies that a patient has a need for wound care supplies? 
Family Physician  24  39  41  38  44  34 
*13.1  *14.4  *14.2  *13.9  *14.5  *9.7 
153  161  220  174  318  2381 
Medical Director of  7  2  9  11  7  9 
Nursing Facility  *7.8  *4.1  *8.3  *8.9  *7.5  *5.8 
45  8  48  50  51  630 
Supplier Representative  2  2  4  2  0  1 
*4.3  *4.1  *5.7  i4.o  *0.O  *2.O 
13  8  21  9  0  70 
Director of Nursing  39  20  30  17  47  25 
*14.9  *11.8  *13.2  *1O.7  *14.6  *8.8 
248  83  161  78  340  1751 
Nurse/Nursing Facility  63  70  59  66  38  70 
Attendant  *14.8  *13.5  *14.2  *13.5  *14.2  *9.4 
401  290  317  302  275  4902 
Wound Care Specialist  20  14  11  4  0  3 
Contracted by Nursing  *12.2  *1O.3.  *9.O  *5.6  *0.O  *3.5 
Facility  127  58  59  18  0  210 
Other (please specify)  17  20  20  23  11  11 
*11.5  *11.8  *11.6  *12.O  *9.1  *6.4 
108  83  107  105  80  770 
No Response  o  0  0  0  2  0 
*0.O  *0.O  *0.O  *0.O  *4.1  *0.O 
o 0 0 0  14  0 
more than one answer was selected by some respondents 
D-7
 11.  Who decides what specific supplies will be ordered for the patient? 
Family Physician  49  66  57  49  62  63 
*15.3  *14.O  *14.3  *14.3  *14.2  *9.9 
312  273  306  224  448  4412 
Medical Director of  10  7  9  13  7  13 
Nursing Facility  *9.2  *7.5  *8.3  *9.6  *7.5  *6.9 
64  29  48  59  51  910 
Supplier Representative  5  0  4  6  0  2 
*6.7  0.0  *5.7  *6.8  *0.O  *2.9 
32  o*  21  27  0  140 
Director of Nursing  56  18  44  17  40  21 
*15.2  *11.4  *14.3  *1O.7  *14.3  *8.3 
356  75  236  78  289  1471 
Nurse/Nursing Facility  29  41  26  43  16  39 
Attendant  *13.9  *14.5  *12.7  *14.2  *1O.7  * 10.0 
184  170  140  197  116  2731 
Wound Care Specialist  22  14  13  9  2  12 
Contracted by Nursing  *12.7  *10.3  *9.7  *8.2  *4.1  k6.6 
Facility  140  58  70  41  14  840 
Inventory Supervisor  7  5  4  0  2  3 
*7.8  *6.4  *5.7  +0.0  k4.1  *3.5 
45  21  21  0  14  210 
Other (please specify)  15  18  9  30  11  18 
*10.9  *11.4  *8.3  *13.1  *9.1  *7.9 
95  75  48  137  80  1261 
No Response  o  0  0  0  2  1 
*0.O  *0.O  *0.O  *0.O  *4,1  *2.O 
o  0  0  0 14 70 
more than one answer was selected by some respondents 
D-8
 12.  How are the wound care supplies initially ordered? 
.,+b...  .,~.: 
.g+  ., *.  : , 
Nursing facility contacts  78  91  76  85  69  80 
supplier  +12.7  *8.5  *12.3  *1O.2  *13.5  *8.2 
496  377  408  388  499  5602 
Supplier is told of need  7  5  9  13  7  5 
when supplier  *7.8  *6.4  *8.3  *9.6  *7.5  *4.5 
representative or delivety  45  21  48  59  51  350 
person visits 
Supplier suggests wound  7  5  4  2  4  3 
care supplies would be  *7.8  *6.4  *5.7  *4.O  *5.7  *3.5 
appropriate  for certain  45  21  21  9  29  210 
patients 
Other (please speeify)  12  7  20  9  16  16 
*9.9  *7.5  *11.6  *8.2  *10.7  *7.5 
76  29  107  41  116  1120 
No Response  o  0  2  2  7  2 
*0.O  *0.O  *4.O  *4.O  *7.5  *2.9 
o  0  11  9  51 140 
* more than one answer was selwted by some respondents 
D-9
 13.	 At which stages of a pressure ulcer, do you use Medieare-reimbursed wound care supplies on 
patients? 
L 
. . :Wqx&?  : .CA  *;  . K,  m.  m  ..Cfl.,H. ER..
Stage  I  2  7  7  4  4  11 
*4.3  *7.5  *7.4  ~5.6  *5.7  *6.4 
13  29  38  18  29  770 
Stage II  12  20  24  15  27  30 
*9.9  +11.8  *12.3  *1O.2  *13.0  *9.4 
76  83  129  69  195  2101 
Stage 111  76  64  52  36  60  63 
*13.1  +14.2  *14.4  *13.7  *14.3  *9.9 
483  265  279  165  434  4412 
Stage IV  59  43  37  60  38  48 
*15.1  *14.6  *14.O  *14.O  *14.2  *10.2 
375  178  199  274  275  3361 
Other (please specify)  12  18  28  36  13  20 
*9.9  *11.4  *13.O  *13.7  *9.8  *8.2 
76  75  150  165  94  1401 
No Response  5  18  15  4  9  10 
*6.7  *11.4  *10.3  *5.6  *8.4  *6.1 
32  75  81  18  65  700 
* more than one answer was selected by some respondents 
SupplierMarketing Practices 
14.  Have supplier representatives ever tried to market their wound care products directly to 
patients? 
!  . .......  .....  ,.  ...,., .,-i 
,.,:.~:;:;~g&:.;  ::;, ,, .;:;::  *::;;  %,,:,: ::,: .:,...:.i.t..i :~~., :N. +,,. ., lx:.,   , Q**
Yes  2  9  4  4  9  5 
i4.3  *8.5  *5.7  *5.6  *8.4  *4.5 
13  37  21  18  65  350 
No  98  89  93  96  89  95 
*4.3  *9.2  *7.4  *5.6  *9.1  *4.5 
623  368  499  439  643  6653 
No Response  o 2 2 0 2  0 
*0.O  *4.1  *4.O  *0.O  *4.1  *0.O 
o  8 11 0 14 0 
D-10  15.	 Have supplier representatives ever helped you determine which patients in your facility qualify 
for Medimre reimbursement of wound care supplies? 
,&s@l$~;  .~ ~  c~     
[Y es  *2122 .7  *2152 .8  *2142 .3  ~4154 .2  *2211930 .3   2*32924.5 1  
140  104  129  206 
No  *7182.7  *7133.1  *7162.3  *1545.2  *6193	.5  4*66979. 62  
496  302  408  251  499 
NOResponse  *o00. O	 *248. 1  *000. O  *000.O  *1244 .1  *7210. O   
16.	 Have supplier representatives ever attemptd  to help you determine which Medimre-eligible 
patients in your facility need various wound care supplies? 
,.  .\..:,. .  .  :.*:.  ;  @?%~_ 
.;.:,* ~~  ~.;:,~v  ~  
 R@@:m.~~   :.::~! ,   
Yes  *1202 .2  *3164 .2  *2122 .O  *1119. 2  *1215229 .1   2*35962. 81  
,127  149  118  87 
No  *8102.2  *6114.4  *7182.O  *1811.2  *7162 .5  *693. 9 
509  253  419  370  549  4412 
No Response  *o0.O	 *24.1  *00.O  *00.O  *24 .1  *21. O 
0  8 0  0 14  70 
17.	 Have supplier reprmentatives ever attempted to help you determine if patients not eligible for 
Medicare need various wound care supplies? 
~.:..,,,...,.:::::..::,.:.,:., 
.,,......,.....:,.,... 
Yes  *1117.5  +2132.4  *2101.6  *2111 .6  *193.8   *285.8  
107  96  94  1751 
108  95 
No  *5812318.5   *3711521.8   *4813010.6   *3715722.O    *6180O47 . 7  5*71931. 12  
No Response  +o0.0  *24.1  *00.O  +24.0  *24 .1  *22 .9 
0  8  0  9 14 140 
D-11
 18.	 Have you ever been offered inducements by suppliers such as free products to allow them to 
provide wound care supplies to your patients? 
Yes  15  23  7  4  22  13 
*10.9  *12.4  *7.4  ~5.6  *12.1  *6.9 
95  95  38  18  159  910 
No  85  75  89  96  73  86 
*10.9  *12.8  *9.O  *5.6  *13.O  *7.1 
541  311  478  439  528  6023 
No Response  o 2 4 0 4  1 
+0.0  *4.1  *5.7  *0.O  *5.7  *2.O 
o  8 21 0 29 70 
If yes, please describe the nature of such inducements. 
19.	 Has a supplier ever provided you with the necessary prescription forms to be filled out by your 
facilitysphysician or the patients familyphysician? 
9  15  34  11  8 
*8.5  *1O.3  *13.5  *9.1  *5.5 
37  81  155  80  560 
91  83  66  84  91 
*8.5  ilo.9  *13.5  *1O.7  *5.8 
377  446  302  607  6373 
0  2  0  4  1 
*0.O	 *4.O  *0.O  *5.7  *2.O 
o  11 0  29 70 
D-12
 20.	 Has a supplier ever filled out the prescription form and presented it to you for the physicians 
signature? 
.  Rafiiti  ..  : .::+.,  ,  ~  ,  . .....lL.  yi  .t~  ~m:,i?qim: 
Yes  2  5  7  21  9  7 
*4.3  *6.4  *7.4  +11.6  *8.4  *5.2 
13  21  38  96  65  490 
No  90  95  91  77  87  92 
*9.2  *6.4  *8.3  *12.0  *9.8  *5.5 
572  393  489  352  629  6443 
No Response  7  0  2  2  4  1 
*7.8  *0.O  *4.O  *4.O  *5.7  *2.O 
45  0  11  9  29  70 
21.	 Does the supplier representative decide the number of supplies to be delivered in a given 
month? 
: +&&&i: ::;..::,:.;,;,~,...., ,.:.,,,~.... ... :;.. . ,:  .,~:  .;~.  ,,Ny.  .:  .+   ti&.,ti., ,...
Yes  7  11  24  34  22  24 
*7.8  *9.2  *12.3  *13.5  *12.1  *8.7 
45  46  129  155  159  1681 
No  90  89  70  60  71  73 
*9.2  *9.2  ~13.2  *14.0  *13.3  *9.1 
572  368  376  274  513  5112 
No Response  2  0  7  6  7  3 
*4.3  *o<o  *7.4  *6.8  *7.5  *3.5 
13  0  38  27  51  210 
22.	 Have you ever been told by a supplier that Medicare requires the use of certain types of 
products on patients suffering from wounds? 
,:,.......,:.:...........:.:,:.,,,.,: .,:,:.,::,:.:,,.:,...:..... ..<.,,;.,...:.:.,.,.. ,...,Q:,,.:,g,.,.&.,..,..:,.&: :. .g..>..,..,.:,j..,.;. ::.;  ...,,...,{,..;,.,.  :,,:::+:;:.:.:,:.:: :::..:~:, :;, :~..,.  .,, .:;.~.:.:. ...:.,   .,,.:..j?q.+:..:.:.,. : . .., ,>~.,.:,::,:..,:,..,..\,,;....:,.,&...,,:,.:,, ,   .. .,.p...~,.,..k,,.,.,,,.: 
Yes  2  20  9  4  13  8 
*4.3  *11.8  *8.3  *5.6  *9.8  *5.5 
13  83  48  18  94  560 
No  95  80  91  96  84  90 
*6.7  +1108  *8.3  *5.6  *1O.7  *6.1 
604  331  489  439  607  6303 
No Response  2  0  0  0  2  2 
*4.3  *0.O  *0.O  *0.O  k4.1  *2.9 
13  0  0  0  14  140 
D-13
 23.	 Have you ever been told by a supplier that Medicare requires the use of wound care@  on 
Medieare beneficiaries? 
j 
&spanie  ,  . . : :.  ...c.. l!.,..:.. $.:.:,  ,.IL.;. ,, r.iy ..~. ..&  &~~  ; 
Yes  5  16  7  4  11  12 
*6.7  *1O.8  *7.4  *5.6  *9.1  *6.6 
32  66  38  18  80  840 
No  95  82  93  %  82  87 
*6.7  *11.4  *7.4  *5.6  *11.2  *6.9 
604  339  499  439  593  6093 
No Response  o 2 0 0 7  1 
*0.O  *4.1  *0.O  *0.O  *7.5  *2.O 
o  8  0  0 51 70 
24.	 Has a supplier ever told you that wound care supplies will be provided to Medicare 
beneficiaries at no cost to the patient? 
,
:$&@.&e  ;..;., :;,  : e&:  fi& .?  ..:i&:. ..NY:  ,q...  ..dii..%......i i,:
Yes  32  27  28  13  22  29 
*14.3  *13.1  *13.0  *9.6  *12.1  *9.3 
204  112  150  59  159  2031 
No  68  73  72  83  69  68 
*14.3  *13.1  *13.O  *1O.7  *13.5  *9.5 
432  302  387  379  499  4762 
No Response  o 0 0 4 9  2 
*0.O  *0.O  *0.O  *5.6  *8.4  *2.9 
o  0  0  18 65 140 
25.  Is the same basic wound care kit provided to every Medicare beneficia~ in your nursing home? 
Yes  22  36  22  13  24  25 
*12.7  *14.2  *12.O  ~9.6  *12.5  *8.8 
140  149  118  59  174  1751 
No  63  45  59  72  51  55 
*14.8  *14.7  +14.2  *12.8  *14.6  *1O.2 
401  186  317  329  369  3852 
No Response  15  18  20  15  24  20 
*10.9  *11.4  *11.6  *1O.2  *12.5  *8.2 
95  75  107  69  174  1401 
D-14
 26.	 Has a supplier ever suggested that a standard number of wound care trays or kits per day (e.g. 
three per day) should be used? 
~=. 
.;?.!:-   =:_~
ii:  ;
Yes  7  9  17  6  18  12 
*7.8  *8.5  *10.9  i6.8  *11.2  *6.6 
45  37  91  27  130  840 
No  90  91  80  87  73  85 
*9.2  *8.5  *11.6  *9.6  *13.O  *7.3 
572  377  430  398  528  5953 
No Response  2  0  2  6  9  3 
*4.3  +0.0  *4.O  *6.8  *8.4  *3.5 
13  0  11  27  65  210 
1 
27.	 Have you ever been told by a supplier that Medicare will cover routine supplies such as saline 
solution if gauze or speeialty dressings are purchased? 
::<.@+&i+e:::;;:::: ::: :  :..,~,, ;.;  ,.,  .,  i+  .,:;: :.IL:;. ::Ni::::  .~ ; . W!@.
Yes  10  14  7  2  16  11 
*9.2  *1O.3  *7.4  *4.O  *10.7  *6.4 
64  58  38  9  116  770 
No  90  86  93  94  76  86 
~9.2  *10.3  *7.4  *6.8  *12.5  *7.1 
572  356  499  430  549  6023 
No Response  o 0 0 4 9  3 
*0.O  *0.O  *0.O  ~5.6  *8.4  *3.5 
o  0  0  18 65 210 
D-15  28.	 Do your suppliers routinely waive the 20 pereent copayment required of Medicare 
beneficiaries? 
r 
ReSFWC  :  .  ,m  ..  IL 
Yes  2  0  9  0  9  2 
*4.3  *oco  *8.3  *0.O  *8.4  *2.9 
13  0  48  0  65  140 
No  29  45  15  43  27  33 
*13.9  *14.7  *10.3  *14.2  *13.O  *9.6 
184  186  81  197  195  2311 
Do Not KtlOW  44  45  70  55  47  58 
+15.2  *14.7  *13.2  *14.2  *14.6  *1O.1 
280  186  376  251  340  4062 
No Response  24  9  7  2  18  8 
*13.1  *8.5  *7.4  *4.O  *11.2   5.5 
153  37  38  9  130  560 
29.	 Has a supplier ever provided a wound care specialist or specialty nurse to assist you in patient 
care or in developing a treatment plan? 
Yes  41  39  22  36  31  37 
*15.1  *14.4  *12.O  *13.7  *13.5  *9.9 
261  161  118  165  224  2591 
No  59  59  74  60  62  62 
*15.1  *14.5  *12.7  *14.0  *14.2  *9.9 
350  244  397  274  448  4342 
No Response  o 2 4 4 7  1 
*0.O  *4.1  *5.7  *5.6  *7.5  *2.O 
o  8  21  18 51  70 
D-16  30.  Has a supplier ever offered training to your staff concerning the treatment and care of wounds? 
J?L. ,  .. .. :%  I.  z%.  OTHER 
Yes  68  68  63  72  51  73 
*14.3  *13.8  *14.0  ~12.8  *14.6  *9.1 
432  282  338  329  369  5112 
No  32  30  35  28  42  25 
*14.3  *13.5  +13.8  *12.8  *14.4  *8.8 
204  124  188  128  304  1751 
No Response  o 2 2 0 7  2 
*0.O  *4.1  *4.O  *0.O  *7.5  *2.9 
o  8  11  0  51 140 
31.  How does your staff become aware of new wound care products that might benefit your 
patients? 
-
i; 
  .; 
56  57  54  68  58  71 
*15.2  *14.6  *14.4  *13.3  *14.4  *9.3 
356  236  290  311  419  4972 
TrainingKlmferenees  59  55  41  60  44  42 
offered by suppliers  *15.1  i14.7  *14.2  *14.O  *14.5  *1O.1 
375  228  220  274  318  2941 
Medieal journalsfliterature  68  68  57  83  49  61 
*14.3  *13.8  *14.3  *1O.7  *14.6  *1O.O 
432  282  306  379  354  4272 
Training provided by  59  61  41  62  36  47 
mediealhursing  *15.1  *14.4  ~14.2  *13.9  *14.0  *10.2 
associations  375  253  220  283  260  3291 
Other (please specify)  20  23  20  23  20  24 
*12.2  *12.4  *11.6  *12.O  *11.7  *8.7 
127  95  107  105  145  1681 
No Response  0 2  7 
*0.O  *4.1  *7.4 
0 8  38 
more than one answer was  Jetted by some re @iiiEii 
D --17
 32.  Have supplier representatives ever requested to review patient medical records? 
t 
B&aIise . .:  :  : ;:.,.c.,~  :. ,.. .:7L;.~i.,,:  ,- ,,  lx  o@ER
Yes  12 16 13 47 11 20 
*9.9  *1O.8  *9.7  *14.3  &91.  *8.2 
76  66  70  215  80  1401 
No  88 82 83 51 84  80 
*9.9  *11.4  *10.9  *14.3  *10.7  *8.2 
560  339  446  233  607  5602 
No Response  o 2 4 2 4  0 
*0.O  *4.1  *5.7  *4.O  *5.7  *0.O 
o  8 21 9 29 0 
If yes, for what reason? 
33.	 Have supplier representatives ever suggested how medical records should be documented to 
support the need for wound care supplies? 
R+*+  .:.,  ..~.,  .  +&  ..,i.  .: : 
,. 
Yes  12  25  9  17  20  17 
*9.9  *12.8  *8.3  *1O.7  *11.7  *7.7 
76  104  48  78  145  1191 
No  85  75  85  81  73  76 
*1O.9  *12.8  *1O.3  *11.2  *13.0  *8.7 
541  311  456  370  528  5322 
No Response  2  0  7  2  7  7 
*4.3  +0.0  *7.4  *4.O  *7.5  *5.2 
13  0  38  9  51  490 
D-18  34.  How many different suppliers provide you with wound care supplies for your patients? 
Number of Suppliers  1.6  2.0  1.4  1.7  1.5  1.7 
*0.4  *0.7  *0.3  *0.3  *0.4  +0.2 
35.	 Please list the names, addresses, and phone numbers of the suppliers who provide your facility 
with the majority of wound care supplies for your patients? 
36.  Are wound care supplies marketed to you in kits or as bulk supplies? 
Both Kits and Bulk  32  30  26  26  31  37  I 
Supplies  *14.3  *13.5  *12.7  +12.5  *13.5  *9.9 
204  124  140  119  224  2591 
Wound Care Kits  20  16  22  9  20  7 
*12.2  +10.8  *12.O  *8.2  *11.7  *5.2 
127  66  118  41  145  490 
Bulk Supplies  32  34  39  43  29  39 
*14.3  *14.0  *14.1  *14.2  *13.3  *1O.O 
204  141  209  197  210  2731 
Other (please specify)  12  5  4  11  7  10 
*9.9  *6.4  *5.7  *8.9  k7.5  *6.1 
76  21  21  50  51  700 
No Response  5  16  9  13  13  8 
*6.7  *1O.8   8.3  *9.6  *9.8  *5.5 
32  66  48  59  94  560 
D-19
 37.  Are wound care supplies shipped to you in kit or bulk form? 
.&::  :$$,.,  iii .  ..NY  , 
 .   
Both Kits and Bulk  *2193 .9  *2132 .4  *2122 .O  +2111 .6  *3113 .5  *299.3  
Supplies	 184  95  118  96  224  2031 
Wound Care Kits  *192.9  *77.5  *2122.O  *66.8  *2101 .7  *45. 5 
76  29  118  27  145  350 
44  41  39  45  31  48 
Bulk Supplies  +15.2  *14.5  *14.1  *14.2  *13.5  *1O.2 
280  170  209  206  224  3361 
7  7  2  13  4  9 
Other (please specify)  *7.8  *7.5  *4.O  *9.6  *5.7  *5.8 
45 29  11 59 29 630 
7  23  15  15  13  9 
No Response  *7.8  *12.4  *1O.3  *1O.2  *9.8  *5.8 
45 95  81 69  94 630 
38.  When  delivered by the supplier, are wound care kits or supplies marked or identified as being 
intended solely for a particular patient? 
Risliie::: :~::
~ :::.; :.:*::  :@  [  
32  27  35  51  33  37 
Yes  *14,3  *13.1  *13.8  *14.3  *13.7  *9.9 
204  112  188  233  239  2591 
59  59  50  34  49  54 
No  *15.1  i14.5  *14.4  *13.5  *14.6  *1O.2 
375  244  269  155  354  3782 
10  14  15  15  18  9 
NO  Response	 *9.2  *1O.3  *1O.3  *1O.2  *11.2  *5.8 
64  58  81  69  130 630 
39.  If suppliers market or ship wound care kits to your facility,what supplies are typimlly 
~ntained  in a kit? 
7 
,*;; :,::@~&
tW  ,.
.:,@;.:+&risk;::  ;:;:: :.:& ..:.:.   . ik  :~c:. 
76  100 60  85  83  75 
Provided Information 
Did Not Provide  24  0  40 15 17 25 
Information 
--mm--- 40.	 If suppliers market or ship wound care kits to your facility, do you typically use all of the 
supplies within those kits? 
ZzIEiiE 
Yes  34  27  35  40  32 
*14.5  *13.1  *13.8  *14.3  *9.5 
216  112  188  289  2241 
No  7  16  17  11  22  15 
*7.8  *10.8  *1O.9  *8.9  *12.1  *7.3 
45  66  91  50  159  1050 
No Response  59  57  48  62  38  53 
*15.1  *14.6  *14.4  *13.9  *14.2  *10.2 
375  236  258  283  275  3712
+ 
If no, what supplies are typically not used? 
Provided Information  33  71  38  20  50  43 
Did Not Provide  67  29  63  80  50  57 
Information 
41.	 Have you ever asked a supplier to make equipment changes, such as removal or addition of 
products, in their standard wound care kit? 
,.::l+-&&  ;{:;::  @,,  ~ .:. it :.;:iL.   .....*...  ::ti....  @iiER:: 
Yes  12  16  11  15  7  17 
*9.9  *1O.8  *9.O  *1O.2  *7.5  *7.7 
76  66  59  69  51  1191 
No  61  57  59  45  76  55 
*14.9  *14.6  *14.2  *14.2  +12.5  *10.2 
388  236  317  206  549  3852 
No Response  27  27  30  40  18  27 
*13.6  *13.1  *13.2  *14.0  *11.2  *9.1 
172  112  161  183  130  1891 
If yes, what changes did you request? 
Provided Information  100  86  100  100  100  81 
Did Not Provide  o  14  0  0  0  19 
Information 
D-21
 If yes, did the supplier make the changes? 
_ :.?%: _ 
Yes  12 11 9  11 7  15 
*9.9  *9.2  *8.3  *8.9  *7.5  *7.3 
76  46  48  50  51 1050 
No  o 5 0 6 0  3 
*0.O  *6.4  *0.O  *6.8  *ooo  *3.5 
o  21 0  27 0 210 
No Response  88 84 91 83 93  82 
*9.9  *1O.8  *8.3  *10.7  *7.5  *7.9 
560  348  489  379  672  5742 
42.  Do suppliers provide you with all the neeessary wound care supplies for each patient once a 
:Ty
NY,. ;:6*: 
Yes  [ 37  &25  37  49  51  39 
*14.8  h12.8  *14.0  *14.3  ~14.6  *1O.O 
235  104  199  224  369  2731 
No  46  45  41  30  27  37 
*15.3  *14.7  *14.2  *13.1  *13.O  *9.9 
293  186  220  137  195  2591 
No Response  17  30  22  21  22  24 
*11.5  *13.5  *12.0  +11.6  *12.1  *8.7 
108  124  118  96  159  1681
If no, how are supplies provided by the supplier? 
Provided Information  74  67  78  79  50  79 
Did Not Provide  26  33  22  21  50  21 
Information 
D-22
 43.  How are wound care supplies stored in your nursing facility? 
z
ZiiiiEl 
.ti,. 
Stored by individual  15  27  24  36  13  29 
patient assignment in  *1O.9  *13.1  *12.3  *13.7  *9.8  *9.3 
supply room  95  112  129  165  94  2031 
Stored in general supply  78  66  70  47  78  66 
room  *12.7  *14.O  *13.2  *14.3  *12.1  *9.7 
4%  273  376  215  564  4622 
Stored by the patients  0  0  0  6 0 2 
bedside  *0.O  *0.O  *0.O  *6.8  *0.O	 *2.9 
o	 0  o  27 o  140 
I 
Other (please speeify)  10  14  9  13  9  11 
*9.2  *1O.3  *8.3  *9.6  *8.4  *6.4 
64  58  48  59  65  770 
No Response  7  11  2  9  9 4 
*7.8  *9.2  *4.O  *8.2  *8.4  *4.O 
45  46  11  41 65  280 
+ 
more than one answer was  ected by some rt  pondents 
44.  What happens to unused or excess supplies? 
. 
& 
12  20  24  53  ~  16
 35
*9.9  *11.8  *12.3  * 14.3  *1O.7  *9.7 
76  83  129  242  116  2451 
Stored for future use by  20  14  24  17  16  26 
specific patient  *12.2  *1O.3  *12.3  *10.7  *1O.7  *9.O 
127  58  129  78  116  1821 
Stored and used as needed  56  36  33  17  40  32 
for all patients  *15.2  *14.2  ~13.6  *1O.7  *14.3  *9.5 
356  149  177  78  289  2241 
Other (please speeify)  15  27  13  13  16  12 
*10.9  *13.1  *9.7  *9.6  *1O.7  *6.6 
95  112  70  59  116  840 
No Response  7  16  9  17  18  9 
*7.8  *10.8  *8.3  *10.7  *11.2  *5.8 
45  66  48  78  130  630 
more than one answer was  XZi&Tl  some respondents 
D-23
 47.  Do you have written or verbal agreements with your wound care suppliers? 
NY w,  \Cyi@Z 
 
12  32  34  20  26 
*9.9  *13.8  *13.5  *11.7  +9.0 
76  132  155  145  1821 
Yes (verbal)  10  2  15  21  4 4 
*9.2  *4.1  *1O.3  +11.6  *5.7  +4.0 
64  8  81  96  29  280 
No  66  59  61  38  60  59 
*14.5  *14.5  *14.1  *13.9  *14.3  *1O.1 
420  244  328  174  434  4132 
No Response  12  7  7 6  16  11 
*9.9  *7.5  *7.4  *6.8  *10.7  *6.4 
76  29  38  27  116  770 
If yes, please  describe  the  nature  of such agreements. 
Provided Information  67  60  60  81  55  71 
Did Not Provide  33 40 40  19  45  29 
Information 
48.	 Have you ever complained to Medicare or other authorities about the marketing or business 
practices of any wound care suppliers? 
Yes  o 0  2 2 9  4 
*0.O  *0.O  *4.O  *4.O  *8.4  *4.O 
o  0  11  9  65 280 
No  90  95  93  94  89  93 
*9.2  *6.4  *7.4  *6.8  *9.1  *5.2 
572  393  499  430  643  6513 
No Response  10  5  4  4  2  2 
*9.2  *6.4  *5.7  *5.6  *4.1  *2.9 
64  21  21  18  14  140 
D-25  If yes, what was the nature of these practices? 
Thank you for completing this survey.  If you have additional  comments  or would like to answer any of the 
questions more jh[ly, please  use the nert page marked Additional  Comments for thir purpose.  Please return 
the survey ti  the self-addressed  postage-paid  envelope we included in our mailing to you or fm  the survey 
and any additional  information to us at (215) 596-6987. 
D-26