..’ 

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENliRAL 

MARKETING OF WOUND CARE


SUPPLIES


@ SERVICE$ 

~+ %., 

* 

JUNE GIBBS BROWN $’ 

: Inspector General
 .
s


%
 #

%.+-+ OCTOBER 1995

%’d~~ 2 0EI-03-94-O0791 
OFFICE OF INSPECTOR 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 Services’ (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 Sefices, the 

Office of Investigations, the Office of Civil Fraud and Adminsitrative Adjudicationand the 

Office of Evacuation and Inspections. The OIG also informs the Secretary of HHS of program 

and management problems and recommends courses to correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’S Office of Audit Sefices (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 OIG’S 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 INSPECHONS 

The OIG’SOffice 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 

Linda M. Ragone, Program Aizaijwt Stuart R. Wright, Program Specialist


Robert A. Baiocco, Program Anai’yst Barbara Tedesco, Technical Support Staff


Cynthia Hansford, Program Assistant Brian P. Ritchie, Technical Suppoti Staff


Emily Tseng, Intern Linda Moscoe, Technical Support Staff


Neil Montovani, Intern


Won Jong Oh, Intern


To obtain a copy of this repo~ please cdl the Philadelphia Regional OfKce at (800) 531-9562

. -

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MARKETING OF WOUND CARE


SUPPLIES


# SERVICEJ 

% #

O~OBER 1995 

~+ Osq 

+ 

JUNE GIBBS BROWN ~v 

:

2 Inspector General 

% 

$--

%’+J~ 2 0EI-03-94-O0791 
EXECUTIVE SUMMARY


PURPOSE 

This report describes supplier and nursing home practices that can lead to 

inappropriate payments for wound care supplies, and examines issues concerning 

Medicare beneficiaries’ use of these supplies. 

BACKGROUND 

Wound care supplies are protective covers or fillers that treat openings on the body 

caused by surgical procedures, wounds, or ulcers. 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 payment to suppliers. The HCFA broadened its coverage policy on 

March 30, 1994, allowing payment for secondary as well as primary dressings and 

including wound treatments by non-physicians. 

The HCFA contracted four Durable Medical Equipment Regional Carriers 

(DMERCS) starting October 1993 to process Part B claims for DME, prosthetics, 

orthotics, and supplies including wound care supplies. These DMERCS developed 

revisions to their guidelines for wound care and requested comments in January 1995. 

These guidelines clarify utilization and medical necessity issues. The effective date for 

implementing the revised guidelines is October 1, 1995. 

This inspection was conducted as part of Operation Restore Trust, a pilot program 

that coordinates Federal, State, and local anti-fraud activity in California, Florida, New 

York, Illinois, and Texas. The program will target abuses in home health agencies, 

nursing facilities, and durable medical equipment, including wound care supplies. 

We collected data from both nursing homes and Medicare beneficiaries for this report. 

We selected a stratified random sample of 420 nursing homes from HCFA’S Online 

Survey Certification and Reporting system and a stratified sample of 469 beneficiaries 

who received Medicare-reimbursed wound care supplies between June 1994 and 

February 1995. 

FINDINGS 

Musing homes and physiciam detemine which patients need supplies but som suppliers 

determine the anumnt providld 

While most nursing facilities indicate that physicians or nursing staff initially identify 

that a patient needs wound care supplies, in 23 percent of nursing homes the supplier 

representative decides the number of supplies to be delivered in a given month. 

i 

— 
.-

Wound care supplies are fhquent~ provided in standurd kit form to beneficiaries. 

More than half of Medicare wound care recipients reported they received their


supplies in kit form. Similarly, almost half (45 percent) of nursing homes using


Medicare-reimbursed wound care supplies received some or all of these supplies in kit


form. Under the new DMERC medical policy to be implemented in October of 1995,


supplies provided in these standardized kits would not be covered.


Some supplierxprovidk inducements to musing homes and beneJiciwies. 

Thirteen percent of nursing homes have been offered inducements in exchange for 

allowing suppliers to provide wound care products to patients in their facility. 

Information from nursing homes and beneficiaries indicates that some suppliers may 

be routinely waiving the Medicare beneficiary coinsurance, a practice that violates the 

Medicare statutes. 

Benefkiaries may not be receiving or using all of the wound care supplies reimbumd by 

Medicare. 

Medicare may be reimbursing for wound care supplies that are not needed by 

beneficiaries since both nursing homes and beneficiaries report not always using all the 

supplies they receive. In addition, many nursing homes have no method of ensuring 

that supplies are used by the beneficiary for which Medicare was billed. Medicare and 

beneficiaries may be paying for wound care supplies that are not used specifically by 

them. 

CONCLUSION 

The information in this report is intended to add to the body of knowledge being 

developed concerning the use of wound care supplies for Medicare beneficiaries. It is 

being issued with two other reports on this subject. These products are part of a 

broader strategic effort designed to assess payments made on behalf of Medicare 

beneficiaries in nursing homes. Information from previous OIG reports coupled with 

the current findings on wound care provide continued support for the effort by HCFA 

to require the bundling of semices in nursing homes. This solution would emphasize 

nursing homes’ responsibilities for management of patient care and provide incentives 

for the appropriate use and prudent purchase of supplies, since it would be nursing 

homes and not suppliers who would receive Medicare reimbursement for these 

supplies. 

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 Indust~ Manufacturers 

Association (HIMA), and the National Association for the Support of Long Term 

ii 
.-. 

Care (NASL). However, I-HMA chose not to provide specific comments on this 

report, The full text of the comments from HCFA and the outside organizations can 

be found in a companion report entitled Questionable Medicare Payments for Wound 

Care Supplies (OEI-03-94-00790). 

The HCFA agreed with the recommendations in the companion report, Questionable 

Medicare Payments for Wound Care Supplies. In addition, HCFA responded that they 

have developed a legislative proposal to require bundling of services, including wound 

care supplies, in Medicare and Medicaid payments to nursing homes. They believe 

that this may seine as an incentive for nursing homes to more closely monitor the use 

of wound care supplies. 

The outside organizations commented that they strongly support HCFAS expansion of 

the national coverage policy for wound care supplies and that no reduction in the 

current scope of the benefit should be considered. They believe that the DMERCS’ 

delay in implementing wound care policies and utilization standards after HCFAS 

expansion of the policy was the primary factor in creating an environment ripe for 

potential abusive practices. Both HIDA and NASL expressed concerns that our 

wound care surveys were misleading and biased and unlikely to provide meaningful 

data. Nevertheless, they both stated that the results of the surveys show that the 

majority of suppliers and facilities act responsibly in operating their businesses. The 

HIDA also responded that we incorrectly implied that legitimate market-driven 

supplier services were inappropriate. 

While we believe the initial lack of DMERC policies without utilization standards for 

wound care supplies played a part in allowing abuses to occur, we do not believe it to 

be the entire cause of abusive supplier practices. Even without specific utilization 

standards, suppliers are supposed to be able to support the medical necessity of the 

wound care products they deliver. 

In response to HIDA and NASL concerns that our surveys for this report were 

misleading and biased, we believe that the questions in our survey were appropriate in 

their wording. The Medicare beneficiary survey was designed to be easily understood 

and completed by the sample population. We do not feel the questions were 

misleading to beneficiaries nor were they intentionally designed to solicit biased or 

untrue information. The nursing home survey was designed to obtain comparable data 

from a large number of respondents on a wide range of issues relating to wound care. 

In response to HIDA’s concerns that we were critical of legitimate services that 

supplier perform on behalf of their customers, we believe that we presented the 

information in a fair manner and did not draw conclusions that could not be 

adequately supported. We are by no means concluding in this report that all suppliers 

are involved in questionable practices. In fact, we highlighted in our companion 

report on questionable Medicare payments that three-quarters of the excessive 

payments we identified in our sample were made to only 7 percent of all suppliers in 

the sample. However, we do believe that some of the practices reported by nursing 

... 

111 
.--

homes and beneficiaries such as determining the number of supplies to be delivered 

and routinely waiving coinsurance amounts raise concerns about the legitimacy of 

certain semices that suppliers provide. 

iv 
.-

TABLE OF CONTENTS 

PAGE 

EXE~ s~y . . ...”””””””””””””””””””” ““””””””””””””””1 

.1


mC)DumON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


7


~lNGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


7


�Nursing home and supplier control over provision of supplies . . . . . . , . . . . . . . . 

. . . . . . 8


�Wound care tits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


. . . . . 9


�upplieri nducements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


10


�Beneficiaries notreceiting or using all supplies . . . . . . . . . . . . . . . . . . . . . . . . .


. 12


CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


APPENDI=


A-1


A Nursing FacilitY Suney Instmment and Response Rates . . . . . . . . . . . . . . . .


B-1


B: Beneficia~ Survey Instrument and Response Rates . . . . . . . . . . . . . . . . . . . .

INTRODUCTION 

PURPOSE 

This report describes supplier and nursing home practices that can lead to 

inappropriate payments for wound care supplies, and examines issues concerning 

Medicare beneficiaries’ use of these supplies. 

BACKGROUND 

Wound care supplies are fillers or protective covers that treat openings on the body 

caused by surgical procedures, wounds, or ulcers. 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 program’s surgical dressing benefit. The coverage policy for these supplies is found 

in section 2079 of the Medicare Carriers Manual. The HCFA contracts four Durable 

Medical Equipment Regional Carriers (DMERCS) to process durable medical 

equipment claims including wound care supplies. The DMERCS issue their own 

guidelines to clarify their coverage policy. 

Medicare Part B Allowances for Wound Care Supplies 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, peaked in 1993 at 

$132 million, then dropped to $98 million in 1994. The number of beneficiaries that 

annually received these supplies ranged from 86,600 in 1993 to as high as 273,300 in 

1991. 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 as one 

product was disallowed in 1992. However, component supplies contained in a kit can 

still be billed as individual products. As a result, the number of billings for 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 Supply Activity 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 

1 II 

No. of Supplies NJA 13 million 45 million 69 million 81 million ~ 

l%e HCFA Broa&ns its Coverage Poliqv for Wound Care Supplies 

On March 30, 1994, HCFA expanded its coverage policy for wound care supplies.


The new policy provides coverage for “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 seine as primary dressings. 

or protective function and typically are needed 

such as adhesive tape, roll gauze, and bandages 

l%e I?ior Coverage Policy Wm More Restrictive 

The HCFA national policy and the DMERCS’ 

more restrictive. Stringent requirements were 

of treatment, cause of wound, type of provider, 

Secondary dressings serve a therapeutic 

to secure a primary dressing. Items 

are examples of secondary dressings. 

policies prior to March 30, 1994 were 

placed on the type of dressings, length 

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 debndement (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. 

.— 
.“ 

Table 2. Comparison of Wound Care Supply Coverage Policies 

IIOnly primary dressings Primary and secondary dressings , I

Time limits on medical necessity As long as medically necessary 

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 

CarrierProce.rszkgof Wound Care Supplies 

In June 1992, HCFA issued a final rule designating four DMERCS to process all 

claims for durable medical equipment, prosthetics, orthotics, and supplies 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). In October 1993, 

HCFA began the transition to the DMERC processing of wound care supply claims. 

During 1994, 56 carriers also processed wound care 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. 

The DMERC3 Implement a Fee Schedule and Intmdke New Codes 

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 wound care supplies. 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. 

The DMERG Issue Dn@ Policy to Clar(ij Wound Care Coverage 

Each DMERC, working with HCF~ developed a policy to clari~ 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 identify 

the number of wound sites being treated. In January 1995, the DMERCS solicited 

comments on these guidelines. After evaluating the comments, the DMERCS issued a 

revised policy to be effective October 1, 1995. 

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 kdustry 

3


—— — 
.. .’ 

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 General Accounting ~ce Discloses Wound Care Supply Abuses 

The General Accounting Office (GAO) issued a final report, Medicare Excessive 

Payments for Medical Supplies Continue Despile Improvements (HEHS-95-1 71), 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 nearly three times higher 

under 29 new wound care codes. They attribute this activity to the absence of a 

clearly defined policy. 

Operation Restore Tlust Tagets Heakh Care Abuse in Five Stat& 

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. The project’s initial focus will be in California, Florida, New 

York, Illinois, and Texas. 

METHODOLOGY 

For the purposes of this report, we collected data from both nursing homes and 

Medicare beneficiaries. 

Numing Home Sampk 

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 HCFA’S 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 

currently 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 

4 
.-

420 nursing homes; the number of nursing homes from each stratum is shown in the 

table below. 

Strata 

California


Florida


Illinois


New York


Texas


Other States


Total 

Nursing Home 

Universe 

931 

565 

700 

584 

964 

9,134 

12,878 

Sample 

60 

60 

60 

60 

60 

120 

420 

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. 

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 nonresponding nursing homes, we decided to use the more conservative responding 

universe. The survey instrument, nursing home responses, and an accompanying 

explanation of the survey results appear in Appendix A. 

Benej%iq Samplk 

To collect information from Medicare beneficiaries who used wound care supplies, we 

sampled beneficiaries for whom Medicare Part B paid at least $20 for wound care 

supplies between June 1994 and February 1995. We selected a stratified random 

sample drawn from the National Claims History 1 percent 

includes allowed claims paid by Medicare in 1994 and the 

selection criteria, we used 85 billing codes which represent 

by beneficiaries requiring wound care supplies. 

After we removed deceased individuals identified through 

Enrollment Database, we found that 624 beneficiaries met 

1 percent sample file. 

sample file. This file 

early part of 1995. As 

the types of supplies used 

information in HCFA’S 

our selection criteria in the 

5

.-

We stratified our sample into the following two groups: individuals with $1,000 or 

more allowed dollars for wound care supplies and individuals with $20 to $999 of 

allowed dollars for wound care supplies between June 1994 and February 1995. We 

sampled 469 beneficiaries; the number of beneficiaries from each stratum is presented 

in the table below. 

Strata Estimated Universe Sample 

Over $1,000 16,900 169 

Under $1,000 45,500 300 

Total 62,400 469 

We mailed questionnaires to 469 beneficiaries across the country, we received 238 

responses for a response rate of 51 percent. The responses from these beneficiaries 

were weighted by stratum and projected to 31,871 beneficiaries nationwide. As was 

the case in the nursing home sample, we chose to project the beneficiary responses to 

the responding universe and not the total universe of beneficiaries (62,400) receiving 

Medicare-reimbursed supplies. We selected the more conservative approach, since we 

did not do an analysis of non-responses and therefore could not determine if there 

would be bias among that group. A sample of the suvey instrument, confidence 

intervals, and beneficiary responses appear in Appendix B. 

This report is one of three reports concerning Medicare payments for wound care 

supplies. A second report, Questionable Medicare Payments for Wound Care Supplies 

(OEI-03-94-00790), identifies questionable billing practices for wound care suppliers 

under Medicare Part B. The third report, Wound Care Supplies: Operahon Restore 

Trust Data (OEI-03-94-00792), provides more detailed billing and marketing 

information on wound care supplies in the five Operation Restore States. 

This inspection was conducted in accordance with the Quali~ Standards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

6

.. -

FINDINGS


NURSING HOMES AND PHYSICIANS DETERMINE WHICH PATIENT’S NEED 

SUPPLIES BUT SOME SUPPLIERS DETERMINE THE AMOUNT’ PROVIDED. 

Nursing home responses indicate that they and not suppliers are responsible for 

determining if a patient needs wound care supplies. More than two-thirds of nursing 

homes report that nurses initially identify a patient’s need for wound care supplies. 

Thirty-five percent indicate that physicians also provide the initial identification. 

However, in some nursing homes, suppliers are determining the amount of supplies 

ordered for patients. While most nursing facilities indicate that physicians or nursing 

staff initially identify that a patient needs wound care supplies, in 23 percent of 

nursing homes the supplier representative decides the number of supplies to be 

delivered in a given month. 

Suppliers have also attempted to determine which nursing home patients need wound 

care supplies. Almost one-third (32 percent) of nursing homes had suppliers attempt 

to determine which Medicare-eligible patients qualified for wound care supplies. 

Wound care suppliers have requested to review medical records in 17 percent of 

nursing homes. These homes report that the reason suppliers give for review records 

is to determine the eligibility of patients, view the physician orders, record treatment 

progression, and to gather supporting documentation for billing purposes. In addition 

to reviewing patient medical records, suppliers have suggested to 17 percent of nursing 

homes how medical records should be documented to support the need for wound 

care supplies. 

More than any other method, nursing homes become aware of new wound care 

products through supplier representatives. Sixty-seven percent of nursing homes 

receive their information about advances in wound care treatment from supplier 

representatives. Forty-five percent of nursing home also have received information 

from training sessions or conferences offered by wound care suppliers. Nursing home 

staff also become aware of new products through medical literature and training 

provided by local medical and nursing associations. Additional avenues for education 

identified by nursing homes include corporate training staffs, enterostomal therapist 

consultants, and word of mouth among nursing home colleagues. 

Seventy percent of nursing homes have had suppliers offer training to their staff 

concerning the treatment and care of wounds. Suppliers have provided wound care 

specialists or specialty nurses in more than one third of nursing homes (36 percent) to 

assist nursing home staff in patient care or in developing a treatment plans. These 

specialists have been provided to nearly half of all nursing h~mes (47 percent) which 

use Medicare-reimbursed supplies. 
.-

Thenursing homes offered mixed review of thehelpfu]ness of supplier assistance and


training. One nursing home responded that the nurse consultants sent to review


wounds in the facility have no more “additional training than staff nurses already


employed by home.” Another nursing home said that after a doctor recommended


using a particular wound care supplier for his patient, it was the supplier


representative and not a nurse that came in to see the patient. This particular nursing


home refused to provide the representative with access to the patient “since he was


not a medical person.” However, a third nursing home reported that their “supplier


has been very helpful when called upon for a challenging skin\wound care situation.”


WOUPJD CARE SUPPLIES ARE FREQUENTLY PRO~ED ~ STAND~


KH’ FORM TO BENEFICLMUES.


More than half of Medicare wound care recipients reported they received their


supplies in kit form. Similarly, almost half (45 percent) of nursing homes using


Medicare-reimbursed wound care supplies received some or all of these supplies in kit


form.


Under the new DMERC medical policy to be implemented in October of 1995,


individual supplies provided in these standardized kits would not be covered. The


policy states that “surgical dressings must be tailored to the specific needs of an


individual patient.” The policy goes on to say that “this cannot be accomplished when


dressings are provided as kits or trays containing fixed quantities and/or multiple types


of dressings.”


The DMERC policy defines a surgical dressing kit as a non-individualized,


standardized packaging containing repetitive quantities of dressings not related to the


individual medical needs of a beneficiary, or whose contents have not each been


prescribed for the care of the specific wounds of that beneficiary, or that contain


materials in addition to surgical dressings.


Many of the kits received by the nursing homes in our survey would not be covered if


one applies the DMERC definition of non-individualized, standard surgical dressing or


wound care kit. Almost one quarter (24 percent) of nursing homes reported that the


same basic wound care kit is provided to every Medicare beneficiary requiring wound


care supplies in their facilities. Only 16 percent of nursing homes have asked a


supplier to make changes to their standard kits.


Many of the wound care kits received by nursing homes also contain many materials in


addition to the surgical dressings that Medicare covers. Thereby, these kits would also


be excluded from coverage based on the new DhlERC policy. When asked to provide


the contents of a typical wound care kit, the items most frequently cited by nursing


homes are listed in the table on the top of the next page. The only items in the table


that are covered by Medicare under the wound care benefits are gauze, tape, and


ABD pads (an absorptive specialty dressing).

1

ITEMS MOST FREQUENTLY INCLUDED 

IN WOUND CARE KITS 

Suppliers have provided musing homes with mideading informatiim in regards to wound 

care E& 

Eleven percent of nursing homes have been incorrectly told by suppliers that Medicare


requires the use of kits when treating a wound. Wound care suppliers in 12 percent of


nursing homes have also suggested that a standard number of wound care kits should


be used per day on patients. Eleven percent of nursing homes have also been


erroneously informed that Medicare will cover routine items such as saline solution if


gauze or specialty dressings are purchased. Medicare does not consider saline solution


a covered item when used for the purposes of moistening dressings or irrigating a


wound.


SOME SUPPLIERS PROVIDE INDUCEMENTS TO NURSING HOMES AND


BENEFICIARIES.


Thirteen percent of nursing homes have been offered inducements in exchange for


allowing suppliers to provide wound care products to patients in their facility.


Seventeen percent of nursing homes with Medicare-reimbursed products have been


offered these inducements. The inducements range from free trial products to


cameras, blenders, and diamond rings.


Suppliers may not be following Medicare regulations with regards to beneficiary


coinsurance. Information from nursing homes and beneficiaries indicates that


suppliers may not be billing beneficiaries for the coinsurance amount. Beneficiaries


are required to pay (unless there is financial hardship) a 20 percent portion of the


costs of their wound care supplies. However, 27 percent of beneficiaries (9,263) did


not pay coinsurance for their wound care supplies nor did they have some other form


of insurance which would have paid the coinsurance amount. In addition, 28 percent


of nursing homes have been told by suppliers that wound care supplies will be


provided to Medicare beneficiaries at no cost to the patient. One nursing home stated

. . 

that suppliers’ “main selling point is ‘it won’t cost your facility, or your residents


anything and we’ll handle all the paperwork.’”


The OIG has in the past taken the position that routine waiver of Part B copayments


may be prohibited under fraud and abuse laws. First, routine waiver may constitute a


violation of the Medicare and Medicaid Anti-Kickback provision, 42 U.S.C. s 1320a-


7b(b), if the purpose of the routine waiver is to induce Medicare or Medicaid business.


Second, a provider’s routine waiver of a beneficiary’s obligation to pay may result in


the filing of a Medicare or Medicaid claim that is false in that it misrepresents the


actual amount charged for the item or sefice. Anti-kickback violations and false


claim may be actionable under criminal, civil, and administrative authorities.


Some suppliers appear to specialize in the Medicare market. One-fifth (20 percent)


of nursing homes report that their suppliers provide wound care products only to the


Medicare eligible patients in their facility. In addition, 31 percent of nursing homes


have had suppliers attempt to determine which patients in their facility qualify for


Medicare reimbursement.


BENEFICIARIES MAY NOT BE RECEIVING OR USING ALL OF THE


WO~ CARE SUPPLIES REIMBURSED BY MEDICARE.


Medicare may be reimbursing for wound care supplies that are not needed by


beneficiaries. Eleven percent of beneficiaries reported they used either none or only


some of the wound care supplies they received. Fifteen percent of nursing homes


report that they do not typically use all of the supplies in wound care kits. The items


most frequently cited as not being used are gauze, ABD pads, and tape. These are


also the only items in a standard kit for which Medicare pays.


More than one-quarter of beneficiaries (28 percent) reported they used wound care


supplies on wounds other than those resulting from surgery on pressure ulcers. Some


of these beneficiaries used these wound care supplies for colostomies and catheters


where in certain instances gauze is covered by Medicare. However, other beneficiaries


used wound care supplies for tracheotomies and feeding tubes. These supplies may be


more appropriately covered under Medicare’s tracheotomy or enteral nutrition


benefits than the surgical dressing or wound care benefit. Beneficiaries also reported


using wound care supplies for skin tears and abrasions which should not be covered


under the Medicare wound care benefit.


Many musinghorns have rw method of ensuring that supplies are used by the benejkimy 

for which M&&are was billed 

The majority of nursing homes indicated that they do not have tracking mechanisms to 

ensure that supplies are used only by the specific beneficiary for which Medicare was 

billed. In almost half of all nursing homes using Medicare-reimbursed supplies (46 

percent), these supplies are not identified or marked for use by specific patients when 

delivered. After receiving wound care supplies, 67 percent of nursing homes take 

10

.. -. 

these supplies and store them in a general supply room. However, several of these 

nursing homes report that if the supply is sent for a specific beneficiary they will store 

them by the patient name in the supply room. 

Medicare and beneficiaries may be paying for wound care supplies that are not used 

specifically by them. More than one-quarter of nursing homes using Medicarereimbursed supplies (26 percent) reported that unused or excess supplies are stored 

and used for all patients in the facility. Another 8 percent of nursing homes reported 

receiving wound care products from suppliers that they did not order. 

11

.-

CONCLUSION


The information in this report is intended to add to the body of knowledge being 

developed concerning the use of wound care supplies for Medicare beneficiaries. It is 

being issued with two other reports on this subject. The first report, Questionable 

Medicare Payment for Wound Care Supplies, describes trends in utilization before and 

after the expansion of Medicare coverage policy for wound care supplies. The second 

report, Wound Care Supplies: Operation Restore Trust States, provides more specific 

utilization and supplier marketing information for California, New York, Illinois, Texas 

and Florida. 

These products are part of a broader strategic effort designed to assess payments 

made on behalf of Medicare beneficiaries in nursing homes. We have previously 

reported on the use of incontinence supplies in nursing homes, nonprofessional 

services in nursing homes, and the range of semices and supplies provided to 

Medicare beneficiaries in skilled nursing facilities. 

Information from these reports coupled with the current findings on wound care 

provide continued support for the effort by HCFA to require the bundling of services 

in nursing homes. This solution would emphasize nursing homes’ responsibilities for 

management of patient care and provide incentives for the appropriate use and 

prudent purchase of supplies, since it would be nursing homes and not suppliers who 

would receive Medicare reimbursement for these supplies. 

AGENCY AND OUTSIDE ORGANIZATIONS’ 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). However, HIMA chose not to provide specific comments on this 

report. The full text of the comments from HCFA and the outside organizations can 

be found in a companion report entitled Questionable Medicare .Payrnents for Wound 

Care Supplies (OEI-03-94-00790). A summary of the comments and our response 

follows. 

HCFA cO17U?’WltS 

The HCFA agreed with the recommendations in the companion report, Questionable 

Medicare Payments for Wound Care Supplies. In addition, HCFA responded that they 

have developed a legislative proposal to require bundling of services, including wound 

care supplies, in Medicare and Medicaid payments to nursing homes. They believe 

that thfi ‘may serve as an incentive for nursing homes to more closely monitor the use 

of wound care supplies. The HCFA also provided us with a technical comment 

12

concerning the need to emphasize the difference between national and regional 

coverage polices on wound care supplies. 

Outw& OganLzations’ Comments 

The organizations commented that they strongly support HCFAS expansion of the


national coverage policy for wound care supplies and that no reduction in the current


scope of the benefit should be considered. They believe that the DMERCS’ delay in


implementing wound care policies and utilization standards after HCFAS expansion of


the policy was the primary factor in creating an environment ripe for potential abusive


practices. While the organizations support the need for implementing DMERC


medical policies for wound care supplies that reflect current clinical practice, they also


believe that some of the utilization standards in the DMERC policy to be


implemented on October 1, 1995 are incorrect and need to be resolved before


implementation occurs. The NASL and HIMA also stated that the DMERC policy


prior to March 30, 1994 that we discuss in the background section of our report was


never fully implemented.


Both HIDA and NASL expressed concerns that our wound care surveys were


misleading and biased and unlikely to provide meaningful data. Nevertheless, they


both stated that the results of the sumeys show that the majority of suppliers and


facilities act responsibly in operating their businesses.


The HIDA responded that we incorrectly implied that legitimate market-driven


supplier services were inappropriate. They reported that they provide critical


functions which hold down or eliminate costs the nursing facility would othenvise


incur. These services include billing/collection activities, bar code technology for order


processing and handling of supplies, delivery/transportation/inventory management


activities, and value added services such as training on product availability an


appropriateness of clinical objectives.


OIG RESPONSE


While we believe the initial lack of DMERC policies without utilization standards for


wound care supplies played a part in allowing abuses to occur, we do not believe it to


be the entire cause of abusive supplier practices. Even without specific utilization


standards, suppliers are supposed to be able to support the medical necessity of the


wound care products they deliver. Some of the examples of questionable billings that


we encountered in our questionable Medicare payments report were not mere


misunderstandings of medical policies for wound care. For example, when suppliers


are billing for amounts large enough to purchase 12.5 miles of tape or 5 gallons of


hydrogel wound filler in a 6-month period this would fall out of even the most


generous clinical guidelines.


We have made changes in the report to reflect the comments that HCFA made about


clarifying the difference between national and local policies. We have also added


13 
.-’�

additional language in the report to emphasize that during the phase-in of the


DMERCS, the previous carriers were still processing claims using their own policies.


In response to HIDA and NASL concerns that our surveys for this report were


misleading and biased, we believe that the questions in our survey were appropriate in


their wording. The Medicare beneficiary survey was designed to be easily understood


and completed by the sample population. We do not feel the questions were


misleading to beneficiaries nor were they intentionally designed to solicit biased or


untrue information.


The nursing home survey was designed to obtain comparable data from a large


number of respondents on a wide range of issues relating to wound care. We realize


that some of these issues are complex and nursing homes may have felt the need to


provide more detailed responses. Therefore, each facility had the option to complete


the “Additional Comments” section of the questionnaire if they felt additional


information was warranted. Many did use this option and also provided additional


information directly underneath many of the questions. This information was included


in our analysis of the data provided by the surveys. In addition, each nursing home


was afforded the opportunity to call our toll-free number if they had concerns or


needed clarification about the survey questions.


In response to HIDAs concerns that we were critical of legitimate services that


supplier perform on behalf of their customers, we believe that we presented the


information in a fair manner and did not draw conclusions that could not be


adequately supported. For many of the sen-ices that HIDA reported suppliers provide


to nursing homes, we did not collect information from nursing homes that would


enable us to evaluate these semices. We did, however, report that suppliers provide


training and technical assistance to nursing home staff. Information on the helpfulness


of this assistance is outlined in our report and includes both favorable and unfavorable


comments by nursing home staff.


We are by no means concluding in this report that all suppliers are involved in


questionable practices. In fact, we highlighted in our companion report on


questionable Medicare payments that three-quarters of the excessive payments we


identified in our sample were made to only 7 percent of all suppliers in the sample.


However, we do believe that some of the practices reported by nursing homes and


beneficiaries such as determining the number of supplies to be delivered and routinely


waiving coinsurance amounts raise concerns about the legitimacy of certain services


that suppliers provide.


We believe the data we received from the surveys was meaningful and presented a


broad picture of supplier and nursing home practices with regards to wound care


supplies, and provided useful information on Medicare beneficiaries use of these


supplies.


14

.. .’�

APPENDIX A


NURSING FACILITY SURVEY INSTRUMENT AND RESPONSE RATES 

Each nursing home in our sample was asked to complete a 48 question survey. 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. 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. 

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 interval. The range of the 95 percent confidence interval is presented in 

the table following each question. 

In the several questions where respondents were asked to provide numerical data 

(e.g., number of beds or percentage of patients receiving wound care supplies), an 

average number or percentage is provided. For questions where we requested textual 

responses, a percentage of respondents who provided written responses is given. 

In addition, when written responses were furnished, these questions were analyzed for 

content and used in the report. However, due to the length of the responses, they are 

not presented in this Appendix. 

There are instances in the report where information from a subset of nursing homes 

which used Medicare-reimbursed wound care supplies for patients is presented. These 

data were developed by evaluating responses from just the 55 percent of nursing 

homes (5,379 projected number of facilities) who answered “yes” to question six of the 

survey- “are any of the surgical dressings or wound care supplies used for patients in 

your nursing facility billed to Medicare Part B.” 

A-1

2. How manybeds does your nursing facility contain? 

Number of Beds 137.1 *11.9 

3. How many patients are currently residing in your facility? 

Number of Patients 111.6 ~8.3 

4. What percentage of your population is eligible for Medicare Part B Coverage? 

Percent Eligible for Medicare Part B Coverage 84.3 *4.O 

5.	 What percentage of your current patient population receive surgical dressings or wound care 

supplies (e.g. gauze, hydrogel or alginate dressings, wound pouches)? 

Percent of Patients Reeeiving Wound Care Supplies 10 +1.8 

6.	 Are any of the surgical dressings or wound care supplies used for patients in your nursing 

facility billed to Medicare Part B? 

Yes 55 *7.5 5380 

No 40 *7.4 3917 

No Response 5 *3.4 474 

A-3

,.. 

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? 1�

Response 

Nursing Facility is sole supplier 

At least one externalsupplier 

Other (pleasespecify) 

No Response 

Rrcent.age 

1 

95%(btikdence 

Inteffaf 

projected Nutdw 

of Nursing Homti 

31 *7. 1 

45 *7.5 

19 *5.9 

5 *3.2 

3005 

4371 

1862 

532 

only to the 

projected NUOIbfZ 

of Nursing IWIW 

1944 

7491 

335 

Projected Number 

~bNtming Homes 

1723 

651 

6182 

3511 

718 

8. Do you have a wound care supplier that provides wound care products 

Medicare-eligible patients in your facility? 

Response 

Yes 

No 

No Response 

9. How did your facility become aware 

Response 

Through supplier advertisements 

Through supplier direct mail 

marketing 

Throughsupplier 

representative/salespersonvisit 

Other (pleasespecify) 

No Response 

Percentage 

20 

77 

3 

of the suppliers 

PercentageR 

18 

7 

63 

36 

7 

95,v. Confidence 

IttK?@@I 

*5.8 

*6.2 

*2.7 

you use? 

95 ‘%Confidence 

Internal 

*6.1 

*4.O 

*7.1 

*7.3 

*3.3 

%more thart orte answerwasselectedby some respondents 

A-4

Use of WoundCare Supplies 

10. Who initially identifies that a patient has a need for wound care supplies? 

Family Physician 35 *7.2 3393 

I I 1 

Medical Director of Nursing 8 *4.2 808 

Facility 

1


Supplier Representative 1 *1.6 134 

I 1 I I 

Director of Nursing 27 *6.6 2662 ‘ 1 1 r 

Nurse/Nursing Facility I 66 I *7.O I 6457 II 

Attendant I I I II 

Wound Care Specialist 5 ~2.8 487 

Contracted by Nursing Facility 

Other (please specify) 13 

I I 

*4.8 

I 

1247 II 

No Response 0.2 +0.3 16 I 

more than one answer was selected by some respondents 

11. Who decides what specific supplies will be ordered for the patient? 

Family Physician 61 k7.3 5975 1 I I 

Medical Director of Nursing 12 *5.O 1157 

Facility ) 

Supplier Representative , 2 

1 

*2.2 

I 

236 

Director of Nursing 25 

I 

k6.2 

i 

2479 

Nurse/Nursing Facility 36 k7.3 3543 

Attendant 

Wound Care Specialist 12 *4.9 1158 

Contracted by Nursing Facility 

Inventoxy Supervisor 3 *2.7 333 

Other (please speci@) 18 

I 1 

*5.8 1 

1726 

No Response 1 *1.5 92 

more than one answer was selected by some respondents 

A-5

. . 

12. How are the wound care supplies initially ordered? 

Response 

Nursing facility contacts supplier 

Supplier is told of need when 

supplier representative or 

delivery person visits 

Supplier suggests wound care 

supplies would be appropriate 

for certain patients 

Other (please specify) 

NO Response 

I%rcentage” 95 ‘%0 Confiden~ Projected ITumber 

Intemai of Nursing Horn= 

80 ~6.O 7802 

6 *3.5 599 

4 +2.7 359 

15 *5.6 1504 

2 *2.2 222 

* more than one answer was selected by some respondents 

13.	 At which stages of a pressure ulcer, do you use Medicare-reimbursed wound care supplies on 

patients? 

* 

Respome Percentage> 95 % Confidence 

Interval 

Projected Number 

Of Nursing Wmm$ 

Stage I 9 ~4.6 892 

Stage II 27 *6.9 2683 

Stage 111 62 *7.3 6039 

Stage IV 48 &7.5 4644 

Other (please specify) 20 *6.O 1937 

No Response 10 *4.5 978 

more than one answer was selected by some respondents 

SuuulierMarketinl!Practices 

14.	 Have supplier representatives ever tried to market their wound care products directly to 

patients? 

Response Permntage 9S ~ Confidence 

Interval 

Pmjectecf Nunti 

of pliursipgHOOlm 

Yes 6 *3.4 541 

No 94 *3.4 9192 

No Response 0.4 +0.4 37 

A-6 
15.	 Have supplier representatives ever helped you determine which patients in your facility qualify 

for Medicare reimbursement of wound care supplies? 

IIYes I 31 I *7.O I 2992 II 

I 68 I *7.1 I 6677 II 

No Response 1 +1.6 102 

16.	 Have supplier representatives ever attempted to help you determine which Medicare-eligible 

patients in your facility need various wound care supplies? 

Yes 32 *7.2 3152 

No 67 *7.3 6517 

No Response 1 *1.6 102 

17.	 Have supplier representatives ever attempted to help you determine if patients not eligible for 

Medicare need various wound care supplies? 

Yes 23 *6.5 2252 

No 75 *6.7 7331 

No Response 2 k2.2 187 II 

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 13 *5.1 1316 

1 

No 85 *5.3 8314 

\ I I 

No Response 1 *1.6 141 

If yes, please describe the nature of such inducements. 

Provided Information 91 

Did Not Provide Information 9 

A-7 
19.	 Has a supplier ever provided you with the necessary prescription forms to be filled out by 

facility’s physician or the patient’s family physician? 

Rqwmse Percentage [ 95 % Cotildence Projected Number 

Interval [ of Nursing Homes 

Yes 10 *4. 1 950 

No 89 *4.4 8685 

No Response 1 *1.6 135 

20.	 Has a supplier ever filled out the prescription form and presented it to you for the physician’s 

signature? 

Yes 7 *3.7 688 , I

IINo 91 *4.1 8907 

I I I I 

No Response 2 *1.7 176 

21.	 Does the supplier representative decide the number of supplies to be delivered in a given 

month? 

22. Have you ever been told by a supplier that Medicare requires the use of certain types of 

Yes ]81 *4.O I 796 

No 90 *4.5 8791 , I 

No Response 2 *2.2 184 

A-8

,-

23.	 Have you ever been told by a supplier that Medicare requires the use of wound care ~ on 

Medicare beneficiaries? 

Response Fercentsge 95 % Confidence Projected Number 

Intervsl of Nursing Homes 

Yes 11 *4.9 1069 

No 88 *5.1 8568 

No Response 1 *1.6 134 

24.	 Has a supplier ever told you that wound care supplies will be provided to Medicare 

beneficiaries at no cost to the patient? 

Yes 28 *6.9 2741 

I 1 

No 70 *7.O 6794 

I I 

No Response 2 *2.2 236 

25. Is the same basic wound care kit provided to every Medicare beneficiary in your nursing home? 

IIYes I 24 I *6,5 I 2393 II 

No 56 *7.5 5489 

No Response 19 ~6.O 1888 

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? 

Response F’ercentage 95’% Confidence” Projected Number 

IIIteNat .‘ of Nursing Homes 

Yes 12 *4.9 1173 

No 84 *5.4 8249 

No Response 4 *2.7 349 

A-9

.-

27. 

28. 

29. 

30. 

Have you ever been told by a supplier that Medicare will cover routine supplies such as saline 

solution if gauze or specialty dressings are purchased? 

I 

Response Percentage 9596 Confidence Projected Number 

Intezw of Nursing I-Iomea 

Yes 11 *4.7 1037 

No 86 *5.3 8421 

No Response 3 *2.7 312 

Do your suppliers routinely waive the 20 percent copayment required of Medicare 

beneficiaries? 

Reqxxtse Percentage ‘ 95 % Contidewe Projected Number 

Interval of Nursing HouIes 

Yes 3 *2.3 279 

No 32 *7. 1 3127 

Do Not KItOW 56 *7.5 5466 

No Response 9 *4. 1 899 

Has a supplier ever provided a wound care specialist or specialty nurse to assist you in patient 

care or in developing a treatment plan? 

Response Per+zrkage “.95 ~ Confidence ~ Projected Number 

Interval , of Nursing Homes 

Yes 36 *7.3 3519 

No 62 57.3 6075 

No Response 2 *1.7 177 

Has a supplier ever offered training to your staff concerning the treatment and care of wounds? 

Yes 70 *6.8 6856 

> 

No 28 *6.6 2693 

No Response 2 *2.2 222 

A-10


—— 
. . 

31.	 How does your staff become aware of new wound care products that might benefit your 

patients? 

Response Percentage” 957. Confidence Projected Number 

Interval of Nursing Homes 

Through supplier representatives 67 *6.9 6561 

Traininfj/Conferen@s offered by 45 *7.5 4383 

suppliers 

Medical journalsfliterature 62 *7.4 6016 

Training provided by 48 *7.5 4661 

medical/nursing associations 

Other (please specify) 23 *6.4 2250 

No Response 1 *0.6 80 

* more than one answer was selected by some respondents 

32. Have supplier representatives ever requested to review patient medical records? 

Response Percentage 95 9ZZC@uliden~

Interval .. 

Projecied Numb 

of Numbg:Hcmes 

Yes 19 *6.O 1878 

No 80 *6.O 7818 

No Response 1 *0.6 75 

If yes, for what reason? 

I Rqcm$e Ekmettiage 

95 

Provided Information 

5 

Did Not Provide Information 

33.	 Have supplier representatives ever suggested how medical records should be documented to 

support the need for wound care supplies? 

A-n 

—. 
34. How many different suppliers provide you with wound care supplies for your patients? 

Number of Suppliers 1.7 *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? 

IIProvided Information


Did Not Provide Information


36. Are wound care supplies marketed 

Both Kits and Bulk Supplies


Wound Care Kits


Bulk Supplies


Other (please specify)


No Response


76 I 

24 

to you in kits or as bulk supplies? 

35 *7.3 3394 

10 *3.9 947 

37 *7.4 3697 

9 *4.5 902 

9 *4.O 831 

37. Are wound care supplies shipped to you in kit or bulk form? 

Both Kits and Bulk Supplies I 28 *6.9 , 2774 

Wound Care Kits 8 *3.6 777 

Bulk Supplies 45 k7.5 4437 1 

Other (please specify) 1 

8 *4.2 786 

No Response 10 *4.3 996 

A-12

.“ 

38.	 When delivered by the supplier, are wound care kits or supplies marked or identified as being 

intended solely for a particular patient? 

IIYes 36 *7.3 3564 , 1 I I 

No 53 *7.5 5201 

I i I I 

No Response 10 *4.3 1006 1 

39. If suppliers market or ship wound care kits to your facility, what suppIies are typically 

contained in a kit? 

Provided Information 78 1! 1 I 

Did Not Provide Information 22 I 

40. If suppliers market or ship wound care kits to your facility, do you typically use all of the 

supplies within those kits? 

Res~nse Percentage 

Yes 32 

No 15 

No Response 53 

If no, what supplies are typically not used? 

Provided Information 11

Did Not Provide Information 

41.	 Have you ever asked a supplier to make equipment 

products, in their standard wound care kit? 

Yes 16 

No 57 

No Response 27 

A-13 

1 

95 % Confidence !-Projected Nu&ber 

InttxVd . ‘ofl!hu,-sing”~,cimes 

*7.O 3140 

*5.4 1481 

*7.5 5150 

45 

I I 

55 II 

changes, such as removal or addition of 

*5.7 1536 

*7.5 5571 

*6.7 2663 
.. . 

If yes, what changes did you request? 

Provided Information 91 11 I 1 

Did Not Provide Information 9 II 

If yes, did the supplier make the changes? 

Yes 14 *5.4 1334 

No 3 *2.6 276 

No Response 84 *5.8 8145 

42.	 Do suppliers provide you with all the necessary wound care supplies for each patient once a 

month? 

Yes 40 *7.4 3868 

No 37 *7.3 3622 

No Response 23 *6.4 2280 

If no, how are supplies provided by the supplier? 

Provided Information 73 

Did Not Provide Information 27 

43. How are wound care supplies stored in your nursing facility? 

Stored by individual patient ! 27 I *6.8 I 2651 !1 II

IIassignment in supply room 

1 I 1 

Stored in general supply room 67 *7. 1 

1 

6563 

Stored by the patient’s bedside 2 , *2.2 

\ 

181 II 

Other (please specifi) 11 *4.7 

I 

1049 I 

No Response 5 *3. 1 513 

more than one answer was selected by some respondents 

II

I

A-14 
.-

44. What happens to unused or excess supplies? 

Returned to supplier 

Stored for future use by specific ! 

patient 

Stored and used as needed for 

all patients 

Other (please specify) 

No Response I 

more than one answer was selectel 

32 k7. 1 3082 

24 k6.6 2326 

33 *7.O 3257 

13 *4.9 1284 

10 *4.3 974 I 

by some respondents 

45. Have you ever received wound care supplies that were not ordered? 

46.	 Do you know if Medicare limits the maximum amount of wound care suppIies allowable for 

payment each month per patient? 

Yes 19 *6.2 1875 

No 71 *6.9 6957 

No Response 10 *4.3 938 

If yes, please describe the limits. 

IIProvided Information 51 

1 

Did Not Provide Information 49 

A-15


—. 
. . 

47. 

48. 

Do you have written or verbal agreements with your wound care suppliers? 

Response Percentage 95 % Confidence Projected NU@JW 

Interval: Of Nursing Homes 

Yes (written) 25 *6.6 2430 

Yes (verbal) 6 *3.2 587 

58 No 

k7.4 5710 

No Response 11 *4.7 1044 

If yes, please describe the nature of such agreements. 

-1 Fercent~~e 

Response 

68 

Provided Information 

32 

Did Not Provide Information 

Have you ever complained to Medicare or other authorities about the marketing or business 

practices of any wound care suppliers? 

If yes, what was the nature of these practices? 

Response Percentage” 

90 

Provided Information 

10 I Did Not Provide Information 

Thank you for completing thti survey, If you have additional comments or would like to answer any of the 

questions more fully, please use the nextpage marked Additional Comments for this purpose. Please return 

the survey in the self-addresse4 postage-paid envelopewe included in our mailing to you orfix the SUYWY 

and any additional information to us at (215) 596-6987. 

A-16

APPENDIX B


BENEFICL%RY SURVEY INSTRUMENT AND RESPONSE RATES 

Medicare beneficiaries in our sample were asked to complete a 19 question survey. 

The answers to these questions provided information on the beneficiaries’ type of 

wound, the treatment of the wound, and the use of Medicare-reimbursed wound care 

supplies. 

For the questions, we report the percentage of beneficiary responses to the question 

and the projected number of responses. 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 31,871 beneficiaries. 

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 interval. The range of the 95 percent confidence interval is presented in 

the table following each question. 

The sample survey instrument with results begins on the next page. 

B-1


_— 
MEDICARE BENEFICIARY SURVEY FOR SURGICAL DRESSINGS 

Our records show that between _ and _ Medicare paid $ for surgical 

dressing/wound care supplies on your behalf.’ Surgical dressing and wound care 

supplies are used for wounds such as surgical incisions and bed sores/pressure ulcers. 

Surgical dressings and wound care supplies include gauze, tape, wound pouches, 

specialty dressings, and other products. 

Please answer the following questions. If you have any problems or questions, please 

call Linda Ragone at 1-800-531-9562. 

1.	 Did you receive surgical dressingshvound care supplies during the time period mentioned 

above? 

Yes 93 *3.4 29,543 I 

No 2 *2.O 7’42 1 I I I 

Do Not KXIOW 4 *2.6 1,338 !1 1 I I I 

No Response 1 *1.1 248 II 

2. Did a doctor tell you to get these supplies? 

Yes 77 *5.4 24,686 

No 11 *4. 1 3,467 

Do Not KIIOW 10 *3.8 3,173 

No Response 2 kL7 545 

3. Did the supplies come packaged in a plastic tray or kit? 

Reapcxke Percentage 95 ‘%Crmfidentx Pmjec$Ed Number 

M3rvat of Beneficiaries 

Yes 54 *6.4 17,205 

No 20 *5.2 6,285 

Do Not KIIOW 25 *5.5 7,837 

No Response 2 *1.7 545 

B-2

4. Were there any types of supplies that you received that you did not need for your wound? 

5. 

6. 

7. 

No 79 *5.2 25,025 , I 11 

Do Not ~OW 16 *4.6 4,960 

No Response 2 *1.7 597 

What portion of the supplies that you reeeived did you actually use? 

Respcmw Percentage 95 % Qmfikkrwe Projected Number 

Interval of. Bessefkiarks 

All 72 *5.7 23,093 

Some 8 *3.5 2,628 

None 3 k2.o 845 

Do Not KllOW 15 *4.5 4,660 

Not Answered 2 *1.8 645 

Were you a resident of a nursing home during the time period mentioned above? 

Response Pmx!ntage 95. % Con fidtxstx lkojecced Number 

Interval 0113enefidarie$ 

Yes 41 *6.O 12,961 

No 58 *6.O 18,513 

Do Not KXIOW 1 *1.3 297 

No Response 0.3 +0.6 100 

Were you receiving services from a home health agency (such as a visiting nurse) during the 

time period mentioned above? 

Yes 38 *6.3 12,183 

No 59 *6.4 18,695 

IIDo Not KllOW 1 *1.4 397 1 

No Response 2 *1.7 597 

B-3

. . 

8. 

9. 

What type of wound did you have that required these supplies? 

Response Percentage 95 % Gmfidence Projected Number 

Interval of 13enefkiaries 

Wound From Surgery 30 *5.9 9,410 

Bed Sore/Pressure Ulcer 43 ~6.O 13,755 

None 1 *1.6 445 

Do Not KItOW 3 *2.4 1,038 

Other (specify) 28 *5.8 8,965 

No Response 4 *2.7 1,387 

How many different wound areas required treatment with these supplies? 

Number of Areas 1.6 *O.18 

10. On what area(s) of the body was your wound(s) 

Chest/Stomach


Back/Buttocks


Leg


Foot


Arm/Hand


None


Do Not KIIOW 

Other (speci&) 

No Response 

more than one 

19 k5. 1 5,940 

24 *5.2 7,750 

27 *5.7 8,620 

32 *5.9 10,220 

8 *3.3 2,635 

1 *1.6 445 

3 *2. 1 842 

17 *4.8 5,505 

3 *2.2 942 I 

answer was selected by some respondents 

B-4

.. -

11. Who decided what kind of dressing or wound treatment supplies you would need? 

12. How many times per dayhveek was the dressing changed? 

Number of Changes per Week 8.8 +0.98 II 

13. Who changed the dressings on your wound(s)? 

Home Health/Visiting Nurse 30 *5.9 9,658 

Physician 7 *3.3 2,232 I 

Nursing Home Staff 33 *5.7 10,382 ! 

Wound Care Product Supplier 0.3 *0.6 100 

Relative/Friend 

Myself 

Do Not WOW 

Other (speeify) 

No Response 

more than one 

19 *5.1 6,092 

20 +5.2 6,530 

3 *2.2 942 

I 

8 *3.6 2,625 I 

2 *1.9 693 

answer was selected by some respondents 

B-5

. . 

2 

14. For how long a period of time did you use the supplies (please answer in days, for example, 

months would be 60 days)? 

Response Average % % Confidence 

Interval 

147.9 *32.7 

Number of Days 

15. Did you receive supplies after your wound was healed? 

Percentage 95 % Confidence prajected Numbfl 

Response IntervaI of Bene@* 

6 +3.0 1,883 

Yes 

71 *5.9 22,506 

No 

10 ~3.8 3,125 

DO Not KnOw 

No Response 14 *4.5 4,357 

16. Did you pay coinsuranu for the surgical dressingsh’ound care supplies reeeived during the 

time period mentioned above? (Coinsuranm is the 20 percent of the bill or Medicare allowed 

amount that you pay the supplier.) 

m.qxmse Percentage 9S % Confidena 

Intervai 

I?mjee[ed Number 

of Benefieiarki 

Yes 32 +6.0 10,155 

No 48 *6.4 15,270 

I 11 

DO Not KxIOw 16 *4.6 5,012 

1.435 5 *2.7 _, .-. II No Response 

17. If you answered no to previous question, did you have any other insurance which would have 

paid the coinsuranm for you? 

Response Percentage 957. Confiden@ 

IntetWd 

Proj-ed Number 

of Ben&iciax’ieS 

Yes 37 ~8.4 6,292 

No 56 *8.7 9,623 

DO Not KtlOw 8 24.5 1,290 

B-6

18. Who filled out this survey? 

Reapottae Percentage 95 % Cmfidtvme Projected Number 

rmcNaf of Btmeficiariea 

I Filled It Out Myself 40 *6.3 12,776 

Someone Filled It Out For Me 58 ~6.3 18,401 

No Response 2 *1.9 693 

19. If someone filled out the survey for you, who are they? 

Response 

Relative


Nursing Home Employee


Friend


Home Health Nurse or Aide


Other (specify)


No Response


Percxwlge 95 % CMidence Projected Number 

Mervaf of Beneficiadea 

38 *6.2 12,148 

10 *3.7 3,228 

3 *2.2 942 

33 *2.4 1,090 

7 *3.3 2,180 

39 *6.3 12,283 

Thank you for completing this survey. If you have additional comments, please write them under 

Additional Comments. Please return the survey in the self-address@postage-paidenvelopewe 

includedin our mailingto you. 

ADDITIONALCOMMENTS: 

B-7