Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MARKETING OF INCONTINENCE 

SUPPLIES 
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 three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation 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 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 010’s 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 efilciency, vulnerability, 

and effectiveness of departmental programs. This report was prepared in the Philadelphia 

Regional Office, under the direction of Joy Quill, Regional Inspector General and Robert A. 

Vito, Deputy Regional Inspector General. 

PHILADELPHIA REGION 

Robert A. Katz, R-eject Leader


Linda M. Ragone, Progam Analyst


Robert A. Baiocco, Rogram Analyst


Cynthia Hansford, Administrative Staff


To obtain a copy of this repor$ please cd 

Project staff included: 

HEADQuARTERs 

Thomas I% Noplock, F70gram Specialist 

Richard P. Lyons, 0jj7ce of Audit Services 

Linda M. Moscoe, Technical Suppoti Staf 

Brian P. Ritchie, Technical Suppoti Stafl 

Barbara Tedesco, Technical Suppoti Staff 

the Philadelphia Regional Office at (MM)531-9562 
Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MARKETING OF INCONTINENCE 

SUPPLIES 
EXECUTIVE SUMMARY 

PURPOSE 

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

inappropriate payments for incontinence supplies, and examines issues concerning 

Medicare beneficiaries’ use of incontinence supplies. 

BACKGROUND 

Medicare Part B expenditures for incontinence supplies have more than doubled tlom


1990 to 1993. In 1993, these expenditures totaled $230 million, up from $88 million in


1990.


Incontinence is the inability of the body to control urinary and bowel functions. Under


the Medicare Part B program, the Health Care Financing Administration (HCFA) will


reimburse suppliers that provide incontinence supplies to aid individuals whose


incontinence condition “...is of long and indefinite duration.” Such reimbursement is


provided as part of Medicare’s coverage for prosthetic devices such as catheters and


external urinary collection devices. The HCFA will also reimburse for accessories such


as irrigation syringes and sterile saline solutions that aid in the effective and


therapeutic use of these devices. Claims for incontinence supplies are now processed


by four Durable Medical Equipment Regional Carriers (DMERCS).


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


We selected a random sample of 180 nursing homes from HCFA’S Online Survey


Certification and Reporting system and a stratified sample of 400 beneficiaries who


received Medicare-reimbursed incontinence supplies in 1993.


FINDINGS 

Inforrnution jhm musinghomes indicatesthatsupplienengagein qu.estikrblk rnak%btg 

practices. 

Twenty-four percent of nursing homes reported that supplier representatives decide 

the number of supplies to be delivered in a given month to beneficiaries. In addition, 

nursing homes reported other questionable practices by suppliers, such as routine 

waiving of beneficiary coinsurance payments and offers of inducements in exchange for 

allowing suppliers to prow’de incontinence supplies to patients. 

Beneficiizritxmuy be receivingunnecessaryor non-coveredsupplies. 

Beneficiary responses indicate that their incontinence problems did not always meet 

Medicare coverage guidelines. Beneficiaries also report that they do not utilize all of 

the incontinence supplies that are reimbursed by Medicare. Of the beneficiaries who 
received these supplies, almost 30 percent said they did not use all the supplies paid 

for by Medicare. 

Numhg homes reprt thatsome supplienrpresentthem withfake or rni$kwhg 

infomlatim 

Twenty-two percent of nursing homes received false information from suppliers stating 

that Medicare is introducing “new broader coverage” for incontinence supplies. one 

out of ten nursing homes has been incorrectly told by a supplier that Medicare will 

cover other routine incontinence supplies such as absorbent undergarments if syringes, 

sterile solutions, and lubricants are purchased. 

Many nursinghomes do not trackMedicare-reimbumedsuppliks to the spec@ b~ 

for whichtheywerebilled 

More than two-thirds of nursing homes (68 percent) store supplies in a general store 

room without patient labels or identification. In addition, almost one-third of nursing 

homes (32 percent) using Medicare-reimbursed incontinence supplies stored excess 

supplies and then used them as needed for all patients. Medicare and individual 

beneficiaries may be paying month after month for unnecessary supplies which maybe 

used for other patients. 

NExT STEPS 

IncontinenceSupplies 

In response to the information presented in this report and a companion report, the 

Office of Inspector General plans to: 

o	 initiate an audit review to examine in more detail payments made for 

incontinence supplies in order to determine if any overpayments are 

involved in this area; and 

o	 launch a national investigation in this area, examining potentially 

fraudulent practices by specific suppliers of incontinence supplies. 

We also support ongoing activity in HCFA and the DMERCS to develop more specific 

coverage guidelines and educate providers and suppliers about proper billing for such 

supplies. We hope the information contained in this report is helpful as they complete 

this activity. 

OIG Studiesof OtherNumingHome Sem”ces 

The OIG will continue studies and audits related to its major initiative examining 

services and supplies provided to Medicare beneficiaries residing in nursing facilities. 

As this report and other OIG work has reflected, the fragmentation of billing for 

ii 
services and supplies provided to residents of nursing homes has created a host of 

improper incentives for billers to the Medicare program. 

Bundh%gof Sewi&r 

We continue to support HCFA’S efforts to pursue a systematic solution to these kinds 

of problems through a requirement for “bundling” of services in nursing home settings. 

Under such an approach, the nursing home would be responsible for providing 

commonly needed services to residents of that facility, rather than allowing for 

separate billing by suppliers. Such a solution would eliminate the incentives suppliers 

now have to aggressively seek out patients in nursing homes and market their products 

inappropriately in those settings. It would also ensure that nursing homes take on 

appropriate responsibilities for services and supplies delivered to residents in their 

facilities. 

... 

111 
TABLE OF CONTENTS


PAGE 

EXECUTIVESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Qi


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


�Questionable marketing practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


.Beneficiaries receiving unnecessary supp]ies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6


�Suppliers present misleading information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7


�NO tracking of Medicare supplies in ntu-singhomes . . . . . . . . . . . . . . . . . . . . . . 9


IW3XT STEPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. O. . . . ...10


APPENDICES


A Nursing Facility Survey Instrument and Response Rates . . . . . . . . . . . . . . . . A-1


B: Beneficiary Survey Instrument and Response Rates . . . . . . . . . . . . . . . . . . . . B-1

INTRODUCTION


PURPOSE 

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

inappropriate payments for incontinence supplies, and examines issues concerning 

Medicare beneficiaries’ use of incontinence supplies. 

BACKGROUND 

Medicare Part B expenditures for incontinence supplies have more than doubled from 

1990 to 1993. In 1993, these expenditures totaled $230 million, up from $88 million in 

1990. 

MedicareCoverageof IncontinenceSupplies 

Incontinence is the inability of the body to control urinary and bowel functions. 

Reimbursement for incontinence supplies are included as part of Medicare’s coverage 

for prosthetic devices. According to Medicare Carriers Manual (MCM) section 2130, 

“prosthetic devices (other than dental) which replace all or part of an internal body 

organ (including contiguous tissue), or replace all or part of the function of a 

permanently inoperative or malfunctioning internal body organ are covered when 

furnished on a physician’s order.” 

Under Medicare Part B, the Health Care Financing Administration (HCFA) will 

reimburse suppliers that provide incontinence supplies to aid individuals whose 

incontinence condition “...is of long and indefinite duration.” Certain items, such as 

absorbent undergarments or diapers, are specifically excluded from coverage. 

Incontinence supplies include prosthetic devices such as catheters and external urinary 

collection devices such as pouches or cups. Catheters are flexible, tubular instruments 

used to control urinary flow. The HCFA will also reimburse for supplies that aid in 

the effective and therapeutic use of these devices. These supplies include items such 

as drainage bags, irrigation syringes, sterile saline solutions, and lubricants. 

Carrier%xzssing of IncontinenceSupplyClaims 

In June 1992, HCFA issued a final rule that designated four Durable Medical 

Equipment Regional Carriers (DMERCS) to process all durable medical equipment, 

prosthetic, orthotic, and supply claims. Effective October 1, 1993, the DMERCS 

replaced more than 50 area carriers which had previously processed DME claims. 

The geographical areas formerly serviced by the carriers were phased in under the 

DMERCS on a staggered basis. The DMERCS are responsible for assuring that 

claims submitted by suppliers meet all applicable coverage and medical necessity 

requirements prior to Medicare reimbursement. Each DMERC issued its own 

1 
coverage and reimbursement policies that implement Medicare guidelines. These


guidelines included appropriate monthly utilization standards for certain supplies like


catheters.


To achieve uniformity in incontinence coverage, the DMERCS issued a draft of a


single, national policy concerning urological supplies in October 1994. The draft policy


redefines and clarifies some of the standards used in processing claims for


incontinence and urological supplies. The policy defines what products meet the


definition of female and male urinary collection devices. It emphasizes the non-


coverage of diapers and similar absorptive pads. The policy also reinforces the


condition of “permanence” for coverage purposes and stresses that incontinence


supplies not used in conjunction with covered catheters or external urinary collection


devices are not covered.


MedicareFraudAlert 

In June 1994, a DMERC issued a Medicare Fraud Alert describing a supplier scheme 

involving the marketing of incontinence kits to nursing homes. In this case, the 

supplier advised nursing home officials that Medicare was paying for the kits under a 

pilot program. According to the alert, supplier representatives exchange kits 

containing diapers along with supplies, such as syringes, saline, and lubricants, to the 

nursing homes in exchange for beneficiary names and health insurance numbers. The 

marketing representatives then order bulk quantities of supplies billed in the 

beneficiary’s name. 

The alert also indicated that the supplier’s marketing program stated that the 

treatment with this kit should be three times per day for each patient in the facility. 

This resulted in Medicare being billed $1,800 per month per beneficiary in one carrier 

jurisdiction. 

METHODOLOGY 

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

Medicare beneficiaries. 

NiusingHome Sample 

To determine how suppliers market incontinence supplies and how nursing homes 

handle the provision of incontinence supplies, we selected a random sample of 180 

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. 

At the time our sample was generated in September 1994, the system contained data 

on 16,642 nursing homes. We decided to sample nursing homes that had a total size 

2

of 60 beds or more. This gave us a universe of 12,879 nursing homes from which we 

sampled for the 180 nursing homes. 

After removing four facilities which were under investigation by the Office of 

Investigations from the sample, we sent identical questionnaires to the administrators 

of the remaining 176 nursing homes. Surveys were returned by 140 nursing homes 

giving us a response rate of 80 percent. 

We chose to project responses only to the responding universe and not to the total 

universe of 12,879 nursing homes. Responses from the 140 nursing homes were 

projected only to the responding universe which would be 80 percent (rounded from 

79.54545) of the 12,879, or 10,245 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. 

Bene@ary Samp12 

To collect information from Medicare beneficiaries who use incontinence supplies, we 

sampled beneficiaries who received Medicare-reimbursed incontinence supplies in 

1993. We selected a stratified random sample drawn from the National Claims 

History 1 percent sample file. This file includes allowed claims paid by Medicare in 

1993. As selection criteria, we used 43 billing codes which represent the types of 

supplies most commonly used by incontinent beneficiaries. 

We found that 4,507 individuals met our selection criteria. This number decreased to 

3,079 after we removed deceased individuals identified through information in HCFA’S 

Enrollment Database. 

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

more allowed dollars for incontinence supplies and individuals with under $1,000 

allowed dollars for incontinence supplies during 1993. We sampled 400 beneficiaries; 

the number of beneficiaries


Strata


Over $1,000


Under $1,000


Total


from each stratum 

Universe 

476 

I 2,603 

I 3,079 

is presented in the table below. 

Sample 

200 

I 200 II 

I 400 II 

3

After selecting the sample and mailing questionnaires to beneficiaries, we decided to 

remove from the sample any beneficiary whose claims might be associated with ostomy 

services. This resulted in removing 81 beneficiary responses from the 302 received. 

After excluding this group, there were 221 respondents used for the analysis. The 

responses from these beneficiaries were projected to 141,932 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 

receiving Medicare-reimbursed supplies. We selected the more consemative 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 survey instrument, confidence 

intervals, and beneficial responses appear in Appendix B. 

This report is one of a series of reports concerning Federal payments for incontinence 

supplies. Questionable Medicare Payments for Incontinence Supplies (OEI-03-94-O0772) 

details trends and expenditures for incontinence payments. The third report, Medicaid 

Payments For Incontinence Supplies (C)E1-03-94-00771), will examine how the Medicaid 

program processes claims for incontinence supplies in 14 States. 

This inspection was conducted in accordance with the Quality Standards for Inspections 

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

4

FINDINGS 

INFORMATION FROM NURSING HOMES INDICATES THAT SUPPLIERS


ENGAGE IN QUESTIONABLE MARKETING PRACIXES.


In some nursing homes, suppliers rather than physicians or nurses maybe deciding 

what amount and type of supplies are ordered for patients. Twenty-four percent of 

nursing homes (2459 of 10,245) reported that supplier representatives decide the 

number of supplies to be delivered in a given month to beneficiaries. Several nursing 

homes commented that suppliers make these decisions based on Medicare regulations. 

However, only half of the nursing homes with patients receiving Medicare reimbursed 

incontinence supplies knew that Medicare limits the amount of certain incontinence 

supplies allowable per month. 

Almost one-quarter (24 percent) of nursing homes reported that supplier 

representatives have helped determine which patients are eligible for Medicare 

reimbursement of incontinence supplies. According to 14 percent of nursing homes, 

supplier representatives have also attempted to help facilities determine which patients 

need incontinence supplies. 

Suppliers in 20 percent of the nursing homes have provided the necessa~ prescription 

forms to be filled out by the patient’s physician. In some nursing homes (7 percent) 

with Medicare-reimbursed supplies, suppliers went a step further and filled out the 

prescription forms and presented it to the nursing home for the physician’s signature. 

Appendix A describes how data was analyzed for the nursing homes using Medicare 

reimbursed supplies. 

One out of five nursing homes have had supplier representatives request to review 

patient medical records. The nursing homes reported that the main reason that 

supplier representatives review medical records is to collect documentation concerning 

the physician’s order, diagnosis, and necessity of the incontinence supplies. Others 

indicated it was to record usage numbers for billing purposes. However, several 

nursing homes said that suppliers do not review the patients medical record but will 

ask nursing home staff to check medical records and provide them with information. 

Another nursing home said they allow the supplier to review patient records but only 

if a staff member is present. 

Some suppliemroutinelywaivethe 20 pement coinsurancepaymentthatMedicare 

benejiciati are requikdtopay. 

Routine waiver of Medicare 20 percent copayments by suppliers is unlawful.


Medicare requires beneficiaries (unless there is financial hardship) to pay a 20 percent


portion of the cost of incontinence supplies. Twelve percent of nursing homes


reported that suppliers routinely waive the 20 percent copayment required of


Medicare beneficiaries. One of every four Medicare beneficiaries (26 percent)


5 
sampled stated that they did not pay coinsurance for their incontinence supplies nor 

did they have any other insurance which would have paid the coinsurance amount. 

While 12 percent of nursing homes said they were aware of suppliers waiving 

copayment fees, another 21 percent did not answer the question. One reason for this 

may be the fact that nursing homes are not always aware of what suppliers are billing 

to Medicare or the amounts that Medicare is reimbursing for the supplies. Of the 

nursing homes that have patients using incontinence supplies paid for by Medicare, 

more than three-quarters utilize external suppliers that directly bill Medicare . 

One nursing home indicated that it was not aware of the amount of money their 

supplier was billing to Medicare for incontinence kits until residents began to receive 

notices of Medicare billings in excess of $900 to $1200 dollars a month and bills for 

large monthly copayment amounts. Upon becoming aware of the supplier’s billing 

practices, the nursing home refused to accept kits from this company. Another 

nursing home related this experience: 

We were approached by a supplier who stated Medicare paid for 

incontinence care. After 15 years of us paying, we decided to try this. 

We were appalled when families called us about the bills. We stopped 

the service immediately. We have not seen this supplier again. 

Some musing homes have been ofl’ed ikducemen~by suppliem. 

Eleven percent of the nursing homes (1127) reported that suppliers had offered them 

inducements, such as free supplies, in exchange for allowing them to provide 

incontinence supplies to their patients. Nursing homes have been provided free 

supplies such as catheter care kits, incontinent pads, and disposable undergarments. 

One nursing home reported that they received free gloves if they ordered incontinence 

supplies and free disposable diapers with the purchase of incontinent kits. 

BENEFICIARIES MAY BE RECEIVING UNNECESSARY OR NON-COVERED


suPPLIEs.


Beneficiary responses indicate that their incontinence problems did not always meet


the coverage guidelines developed by HCFA. Medicare guidelines require


beneficiaries to have a diagnosis of permanent urinary incontinence in order to receive


incontinence supplies. However, 15 percent of the beneficiaries with incontinence


conditions related that they experienced problems only sometimes or rarely.


Beneficiaries also report that they do not utilize all of the incontinence supplies that


are reimbursed by Medicare. Of the beneficiaries who received these supplies, almost


30 percent said they did not use all the supplies paid for by Medicare. As illustrated


in the chart on the next page, while 15 percent said they used most the of the supplies


another 14 percent stated they used some or none of the supplies.


6

Portion of Incontinence Supplies	

Used by Beneficiaries	

MOST 

15% 

DON” T RECALL I 

- 13% 12% 

NONE 

2% 

%~ercentages have been rounded to the nearest whole number 

NURSING HOMES REPORT THAT SOME SUPPLIERS PRESENT THEM WITH


FALSE OR MISLEADING INFORMATION.


Nursing homes reported incidents where suppliers furnished false or misleading 

statements about Medicare coverage policies. This may lead to non-covered or 

unnecessary services being billed to Medicare and possibly to beneficiaries. 

Twenty-two percent of nursing homes received false information from suppliers stating 

that Medicare is introducing “new broader coverage” for incontinence supplies. 

Another six percent of nursing homes have been told by suppliers that Medicare 

requires the use of syringes, sterile saline solutions, and lubricant/skin barriers on 

incontinent patients. As one supplier put it, “we’ve seen this when suppliers are trying 

to sell products that don’t meet the Medicare criteria.” 

Medicare does not cover supplies such as disposable incontinent briefs or absorbent 

undergarments or pads. There are indications, however, that suppliers may be 

marketing these products as female external urinary collection devices. Figure 1, on 

the following page, is an illustration of an actual pouch type female urinary collection 

device. The device is a plastic pouch which is attached to the body with adhesives and 

has a drainage port at the other end. This device would meet Medicare guidelines for 

coverage. Figure 2 is an illustration of what one supplier is calling a pouch-type 

female urinary collection device in information provided to nursing homes. This 

7 
MANY NURSING HOMES DO NOT TIWC!K MEDICARE-REIMBURSED


SUPPLIES TO THE SPECIFIC BENEFICIARY FOR WHICH THEY WERE


BILLED.


In many nursing homes there appears to be no tracking system to ensure that all of 

the incontinence supplies billed to Medicare for a specific patient are used for that 

patient. Almost two-thirds of nursing homes (62 percent) using Medicare-reimbursed 

incontinence supplies report that when supplies are delivered by suppliers they are not 

marked or identified as being intended solely for a particular patient. Then after 

receiving the supplies, more than two-thirds of nursing homes (68 percent) store them 

in a general store room without patient labels or identification. 

Since the majority of nursing homes did not indicate the existence of any specific 

tracking mechanism for Medicare-reimbursed supplies, Medicare and individual 

beneficiaries may be paying month after month for unnecessa~ supplies which maybe 

used for other patients. In fact, almost one-third of nursing homes (32 percent) using 

Medicare-reimbursed incontinence supplies stored unused excess supplies and then 

used them as needed for all patients. 

Several nursing homes did report that supplies are tracked for usage by specific 

beneficiaries and subsequently billed to Medicare only when used. Some of these 

nursing homes explained that when the supply is removed from the supply room for 

usage it is logged on to a patient usage sheet. Other nursing homes described that 

Medicare-reimbursed supplies were kept in supply rooms that contained only 

Medicare Part B supplies. 

9

NEXT STEPS�

IncontinenceSuppi’kx 

In response to the information presented in this report and a companion report, the 

Office of Inspector General plans to: 

o� initiate an audit review to examine in more detail payments made for 

incontinence supplies in order to determine if any overpayments are 

involved in this are% and 

o� launch a national investigation in this area, examining potentially 

fraudulent practices by specific suppliers of incontinence supplies. 

We also support ongoing activity in HCFA and the DMERCS to develop more specific 

coverage guidelines and educate providers and suppliers about proper billing for such 

supplies. We hope the information contained in this report is helpful as they complete 

this activity. 

OIG StudiesOf OtherN&g Home Services 

The OIG will continue studies and audits related to its major initiative examining 

services and supplies provided to Medicare beneficiaries residing in nursing facilities. 

As this report and other OIG work has reflected, the fragmentation of billing for 

services and supplies provided to residents of nursing homes has created a host of 

improper incentives for billers to the Medicare program. 

Bundliizgof Sen.kes 

We continue to support HCFA’S efforts to pursue a systematic solution to these kinds 

of problems through a requirement for “bundling” of services in nursing home settings. 

Under such an approach, the nursing home would be responsible for providing 

commonly needed services to residents of that facility, rather than allowing for 

separate billing by suppliers. Such a solution would eliminate the incentives suppliers 

now have to aggressively seek out patients in nursing homes and market their products 

inappropriately in those settings. It would also ensure that nursing homes take on 

appropriate responsibilities for services and supplies delivered to residents in their 

facilities. 

10

APPENDIX A�

NURSING FACILITY SURVEY INSTRUMENT AND RESPONSE RATES 

Each nursing home in our sample was asked to complete a 39 question survey. The 

questions for the survey were developed by reviewing information on incontinence 

supplies produced by HCF~ the Durable Medical Equipment Regional Carriers, and 

the Office of Investigations within the OIG. 

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 10,245 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 multiplies 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 incontinence 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 incontinence supplies for patients is presented. 

These data were developed by evaluating responses from just the 75 percent of 

nursing homes (7,584 projected number of facilities) who answered “yes” to question 

six of the survey- “are any of the incontinence supplies used for patients in your 

nursing facility billed to Medicare Part B.” 

A-1

INCONTINENCE SUPPLIES: NURSING FACILITY SURVEY 

This survey is being conducted by the Oftice of Evaluation and Inspections within the U.S. Department 

of Health and Human Services’Offke of Inspector General. We are currently reviewing Medicare’s 

payments for incontinence supplies. We are also interested in learning about equipment suppliem’ 

marketing practices for incontinence supplies. 

Our review is focusing on Medicare Part B payment of incontinence supplies. Please keep this in mind 

when completing this survey. We are not at this time interested in incontinence supplies that are 

included in Medicare Part A cost reports. 

All information DrOVidedwill be keDt confidential. All data will be reported out in the amreeate and 

the namesof nurshv!facilitieswill never be identified to the Dublic. If you have any questions about 

this survey, please call Robert Katz or Linda Ragone at 1-800-531-9562. 

Please return this survey by September 15, 1994 in the enclosed self-addressed, pre-paid envelope or if 

you prefer you can fax it to us at (215) 5%-6987. We appreciate your cooperation and assistance. 

Pklseprilu & fouowing rnfmmation@kzsefirtasthenqmn&mtthept7sonwho ans Wersthemq 

W@@@’ 

RESPONDENT


JOB TITLE


NURSING FACILITY:


ADDRESS:


TELEPHONE


General Information


A-2

2. How many beds does your nursing facility contain? 

Number of Skilled Nursing Beds 63.2 ! *10.9 I 

Number of Nursing Beds 62.3 *9.6 II 

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

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

Pereent Eligible for Medieare Part B Coverage 83.3 *3.2 

5.� What percentage of your current patient population receive incontinence supplies (e.g. 

indwelling catheters, external urinary and fecal collection deviees, irrigation syringes, sterile 

irrigation solutions, skin barriers, lubricants)? 

Percent of Patients Receiving Incontinence Supplies 2s.4 *5.2 

6.� Are any of the incontinence supplies used for patients in your nursing facility billed to 

Medicare Part B? 

A-3

7.� Does your nursing facility act as the sole supplier for incontinence supplies by billing Medicare 

Part B or do you have at least one external supplier of incontinence supplies? 

Nursing Facility is sole supplier 19 �6.5 1947 I I I 

At least one external supplier I 69 

I 

*7.7 

I 

7069 

Other (please specify) I 

6 

I 

*3.9 

I 

615 

No Response 5 *3.6 512 

Use of Incontinence Sumiiea 

8. Who decides that a patient has a need for incontinence supplies? 

Family Physician 69 *7.7 7069 

Medical Director of Nursing 9 *4.7 922 

Facility 

Supplier Representative I o o 

Nurse/Nursing Facility 54 *8.3 5532 

Attendant 

Invento~ Supervisor 1 *1.6 102 

Other (please specify) 14 *5.7 1434 

No Response 1 *1.6 102 

more than one answer was selectedb y some respondents 

9.� What medical conditions need to be present in order for you to order incontinence supplies for 

Medicare beneficiaries? 

Physical dysfunction of urinary 77 *7.O 7889 

or intestinal tracts 

Permanent Urinary Incontinence 49 *8.3 5020 

Need for indwelling catheter 54 *8.3 5532 

I 1 I 

Alzheimer’s/Dementia 16 *6.1 1639 

I I I 

Other (please specify) 16 *6.1 1639 I I I 

No Response 4 *3.2 410 

more than one answer was selected by some respondents 

A-4 
10. Who deeides what specific supplies will be ordered for the patient? 

Family Physician I 54 I *8.3 I 5532 

Medical Director of Nursing 9 *4.7 922 

Facility 

Supplier Representative 4 *3.2 410 

Manufacturer of Supplies 1 +1.6 102 

Nurse/Nursing Facility 59 *8.1 6045 

Attendant 

Inventory Supervisor I 11 I *5.2 I 1127 

Other (please specifi) I 14 I *5.7 I 1434 

No Response 2 *2.3 205 

more than one answer was selected by some respondents 

11. How are the incontinence supplies initially ordered? 

Nursing facility contacts supplier 

Supplier is told of need when 

supplier representative or 

delivery person visits 

Supplier suggests incontinence 

supplies would be appropriate 

for certain patients 

Other (please speci$) 

No Response 

81 *6.5 8298 

15 *5.9 1537 

3 �2.8 307 

12 *5.4 1229 

2 *2.3 205 

more than one answer was seleeted by some respondents 

A-5

,,,. . . . ...:.:: .::. ~:::

.

. . .“.”. “”.’.“. ... .“ . ...........

SumlierMarketiwPraeticea 

12. How did your facility become aware of the suppliers you use? 

._’:,..., ,.. ., ,,,.’.,.:,. .,, ,. ,,:... ,.:,., ,:,,:,::, ,,.:.::.., , ..:.:.:. ,: :,,., ,:, . :,,., >.::.,,:. ,;,, :,,. 

.,,,.’.’... :::%t&+@””’f”; “~!’:”:::::.!.:: P&%i#@l ““:+ :“$x%”.wwiti%:i:i;?.tijwwiNu#k*: ,. .”.”.’ “.”- j. ,< .,,..: :,:,’: ...#tit6iWKw :., ,’‘:.,.:: ‘. . .“ .“ .:...“ “. 

.:..-.,. ‘::?“lxM@iiig*q; ..’: 

Through supplier advertisements 

Through supplier direct mail 

marketing 

Through supplier 

representative/salesperson visit 

Other (please speeify) 

No Response 

.... . .,.,... ..... 

10 +5.0 102.5 

6 *3.9 615 

61 *8.1 6249 

32 *7.7 3278 

5 *3.6 512 

%more than one answer was selected by some respondents 

13. How many different suppliers provide you with incontinence supplies for your patients? 

A-6

16.� Have supplier representatives ever attempted to help you determine which patients in your 

facility need incontinence supplies? 

Yes 14 *5.7 1434 

No 83 *6.2 8503 

I 

No Response 3 *2.8 307 

17.� Have supplier representatives ever helped you determine which patients in your facility quali& 

for Medicare reimbursement of incontinence supplies? 

Yes 24 *7.1 2459 

No 73 *7.4 7479 

No ReSDOnse 3 *2.8 307 

18.� Have you ever been offered inducements by suppliers such as free products to allow them to 

provide incontinence supplies to your patients? 

Yes 11 *5.2 1127 

No 85 *5.9 8708 

No ResDonse 14 \ +3.2 I 410 

If yes, please describe the nature of such inducements. 

IIProvided Information 13 

1 II 

Did Not Provide Information 87 

19.� Has a supplier ever provided you with the necessary prescription forms to be filled out by your 

facility’sphysician or the patient’s family physician? 

Yes 20 *6.6 2049 

No 78 *6.9 7991 

No Res~onse 2 *2.3 205 

A-7 
20.	 Has a supplier ever filled out the prescription form and presented it to you for the physician’s 

signature? 

Yes 6 *3.9 615


No 89 ‘ *5.2 9118


No RW)OIN2 5 *3.6 512


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

month? 

22. Have you ever received information from a supplier stating that Medicare is introducing new 

Yes 6 *3.9 615 I


No 91 *4.5 9323
 I I I 1


No Response 3 *2.8 307


A-8

24.� Have you ever been told by a supplier that Medicare will cover other routine inecmtinemx 

supplies such as absorbent undergarments or pouches if syringes, sterile solutions, and 

lubricants are purchased? 

IIYes I 10 I ,5.0 \ 1025 

No 87 *5.6 8913 

No Response 3 �2.8 307 

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

beneficiaries? 

Yes 12 *5.4 1229 

No 66 *7.8 6762 

No Response 21 *6.7 2151 

26. Have supplier representatives ever requested to review patient medieal records? 

Yes I 21 I *6.7 I 2151 

No I 74 I *7.3 I 7581 

No Response 4 *3.2 410 

If yes, for what reason? 

IIProvided Information 24 

I 

Did Not Provide Information 76 

A-9


I 
27. Are incontinence supplies marketed to you in kits or as bulk supplies? 

1

Incontinence Kits 14 *5.7 1434 I I I 

Bulk Supplies I 

56 I *8.2 I 

5737 I 

Both Kits and Bulk Supplies I 

16 I 

*6.1 I 

1639 I 

Other (please speei&) I 

10 

I 

*5.O 

I 

102s 

1 

No Response 7 *4.2 717 

II

more than one answer was selected by some respondents 

28. Are incontinence supplies shipped to you in kit or bulk form? 

Incontinence Kits 10 *5.O 102s

1 

Bulk Supplies 61 *8.1 6249

I 

Both Kits and Bulk Supplies 16 ~6.1 1639 

I I 1 

Other (please speei~) 8 *4.5 820 

I I I 

No Response 8 *4.5 820 

more than one answer was selected by some respondents 

29.� When delivered by the supplier, are incontinence kits or supplies marked or identified as being 

intended solely for a particular patient? 

Yes 28 *7.4 2869 

No 63 *8.O 6454 

No Response 9 *4.7 922 

30.� If suppliers market or ship incontinence kits to your facility,what supplies are typically 

contained in a kit that is not used for the insertion of a mtheter? 

Did Not Provide Information 73 I 

A-10

31.� If suppliers market or ship incontinence kits to your facility, do you typically use all of the 

supplies within those kits? 

32. 

33. 

Yes 39 *8.1 3996 

No 14 *5.7 1434 

No Response 48 *8.3 4918 

If no, what supplies are typically not used? 

IIProvided Information I 

8 I 

! Did Not Provide Information I 92 u 

Do suppliers provide you with all the necessary incontinence supplies for each patient once a 

month? 

Yes 50 *8.3 5123 

No 36 *8.O 

No Response 14 *5.7 1434 

If no, how are supplies provided by the supplier? 

IIProvided Information I 28 II 

Did Not Provide Information 72 II 

How are incontinence supplies stored in your nursing facility? 

IIStored by individual patient I 18 I *6.4 I 1844 II 

IIassignment in supply room 

1 I I I 

IIStored in general supply room 74 *7.3 7581 

r 1 1 I

IIStored by the patient’s bedside 

I 

8 

1 

*4.5 

1 

820 II 

Other (please specify) 9 *4.7 922

1 1 I 

No Response 6 *3.9 615 

more than one answer was selected by some respondents 

A-II 
34. What happens to unused or excesssupplies? 

Returned to supplier 26 *7.3 

Stored for future use by specific 23 *7.O 2356 

patient 

Stored and used as needed for 34 *7.8 3483 

all patients 

Other (please speci&) 12 *5.4 1229 

No Rewonse 1 11 1 *5.2 1 1127 1 . II

4 more than one answer was selected by some respondents 

35. Have you ever received suppIies that were not ordered? 

36. Have you ever received supplies where no specific beneficiary was identified? 

37.� Do you know if Medicare limits the maximum amount of incontinence supplies allowable for 

payment each month per patient? 

Yes 42 *8.2 4303 I


No 51 *8.3 522S


No Response 6 *3.9 615


A-12

If yes, please describe the limits. 

IIProvided Information I 36 II 

i Did Not Provide Information I 64 u 

38. Do you have written or oral agreements with your incontinence suppliers? 

39. 

Yes 37 �8.O 3791 

No 54 *8.3 5532 

No Response 9 �4.7 922 

If yes, please deseribe the nature of such agreements and enclose a copy of any written 

agreements. 

]]Provided Information I 31 II 

Did Not Provide Information 69 

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

practices of any suppliers? 

Yes 6 

1 1 

*3.9 615 

No 91 

I 1 

*4.5 9323 

No Response 4 *3.2 410 

If yes, what was the nature of these practices? 

Thank you for completing this survey. If you have additwnal comments or would like to answer any of the 

questbts more I?@, please u.rethe next page marked Aaiiitional Comments for this putpose. Please return 

the survey in the self-addressed postage-paid envelope we included in our mailing to you or fzx the survey 

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

A-13 
APPENDIX B�

BENEFICIARY SURVEY INSTRUMENT AND RESPONSE RATES 

Medicare beneficiaries in our sample were asked to complete a short six question 

survey. The answers to these questions provided information on the severity of their 

incontinence conditions and the use of supplies for their condition. 

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 141,932 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 mutiplies 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

OUR RECORDS SHOW THAT BETWEEN ._. AND


MEDICARE PAID FOR SUPPLIES RELATED TO =ONTINENCE ON


YOUR BEHALF.


FOR THE PURPOSES OF THIS SURVEY, INCONTINENCE SUPPLIES


INCLUDE EQUIPMENT AND PRODUCTS INTENDED FOR PERSONS WHO


HAVE PROBLEMS WITH BIADDER AND/OR BOWEL CONTROL.


PLEASE ANSWER THE FOLLOWING QUESTIONS. 

1.� DID YOU RECEIVE INCONTINENCE SUPPLIES DURING THE TIME 

PERIOD MENTIONED ABOVE? SUCH SUPPLIES COULD HAVE 

INCLUDED CATHETERS, GAUZE PADS, ABSORBENT 

UNDERGARMENTS (SIMILAR TO DIAPERS), LUBRICANTS, 

DRAINAGE AND COLLECTION DEVICES, OR STERILE LIQUIDS. 

All 59 *9. 1 66,578 

I

1 

Most 15 *6.4 16,950 I I I 

Some 12 ~6.O 

1 13,030 

None 2 *2.3 2,254 

Do Not Recall 13 *6.3 14,570 

Yes 59 

I 

*8.3 

1 82,955

No 36 *8. 1 50,915 

Do Not Recall 1 *1.8 1,540 

No Response 5 *3.2 6,522 

B-2 
3.
 WERE YOU RECEIVING SERVICES FROM A HOME HEALTH AGENCY (SUCH AS A 

VISITING NURSE OR AIDE) DURING THE TIME PERIOD MENTIONED ABOVE? 

Yes 13 *6.O 

1 19,061 I 

No 78 *6.8 

1 

110,651 

II 

Do Not Recall 4 *2.6 

1 5,221 I 

No Response 5 *3.2 6,998 

4.
 DID YOU PAY COINSURANCE (THE USUAL 20 PERCENT OF THE AMOUNT 

MEDICARE ALLOWS FOR SUPPLIES) FOR INCONTINENCE SUPPLIES RECEIVED 

DURING THE PERIOD MENTIONED ABOVE? 

5.
 DURING THE TIME PERIOD MENTIONED ABOVE, DID YOU HAVE ANY 

PROBLEMS ASSOCIATED WITH BLADDER OR BOWEL CONTROL? 

B-3

IF YOU ANSWERED YES TO QUESTION 5, HOW OFT’ENDID YOU EXPERIENCE 

SUCH PROBLEMS? (CHECK ONE BLOCK) 

WHEN YOU COMPLETE THE SURVEY FORM- PLEASE IU?lUIW IT TO US IN THE 

ENcLXXED POSTAGE-PAIDENVELOPE 

IF YOU HAVE ANY QUESTIONS REGARDING THIS SURVEY>


PLEASE CALL RICHARD LYONS, PROJECT DIRECTOR, AT (410) 966-3143.


PLEASE USE THE SPACE BELOW IF YOU WISH TO ADD ANY ADDITIONAL COMMENTS 

B-4

. 

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MARKETING OF INCONTINENCE 

SUPPLIES 

JUNE GIBBS BROWN 

Inspector General 

DE_ER 1994 

OEI-03-94-00770 

— 
OFFICE OF INSPE(XOR 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 three OIG operating components: the Office of Audit Seti=$ the 

Office of Investigations, and the Office of Evaluation 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 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 010’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 INSPECI’IONS 

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 Joy Quill, Regional Inspector General and Robert A. 

Vito, Deputy Regional Inspector General. Project staff included: 

PHILADELPHIA REGION HEADQuARm 

Robert A. Katz, Project Leader Thomas A. Noplock, Program Specialist 

Linda M. Ragone, Progam Analyst Richard P. Lyons, Ofice of Audit Services 

Robert A. Baiocco, fiogram Analyst Linda M. Moscoe, Technical Suppoti Stafl 

Cynthia Hansford, Administrative Stafl Brian P. Ritchie, Technical Support Stafi 

Barbara Tedesco, Technical Support Sta# 

To obtain a copy of this repo~ please call the PhiladelphiaRegional Off&at (800) 531-9562.