Medicare: Second Year Update for CMS's Durable Medical Equipment Competitive Bidding Program Round 1 Rebid
Published: 2014-03-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: To achieve Medicare savings for DME, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 required that CMS implement the CBP for certain DME. In 2008, the Medicare Improvements for Patients and Providers Act terminated the first round of supplier contracts and required CMS to repeat the CBP round 1—referred to as the round 1 rebid, resulting in the award of contracts to suppliers with CBP payments that began January 1, 2011.
GAO was asked to review issues concerning the rebid's second year of operation—2012. This report reviews the round 1 rebid's effects on (1) Medicare beneficiaries, (2) the market share of contract suppliers, and (3) all suppliers, including both contract and non-contract suppliers (the suppliers not awarded rebid contracts.) To examine the effects on Medicare beneficiaries, GAO compared Medicare claims data for 2011 and 2012 with that for 2010, the year before the round 1 rebid. GAO also examined other information about CMS's efforts to monitor the effects of the CBP, and interviewed DME industry representatives and officials from Medicare beneficiary organizations. To examine the effects on both contract and non-contract suppliers, GAO compared Medicare claims data for 2012 with that for 2010 and analyzed other data provided by CMS.
section_title: What GAO Found
paragraphs: The Medicare competitive bidding program (CBP) for durable medical equipment (DME) is administered by the Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services. Under the CBP, only competitively selected contract suppliers can furnish certain DME product categories (such as oxygen supplies and hospital beds) at competitively determined prices to Medicare beneficiaries in designated competitive bidding areas. The CBP's round 1 rebid was in effect for a 3-year period, from 2011 through 2013. It included nine DME product categories in nine geographic areas. For CBP monitoring purposes, CMS also selected nine comparator areas that were demographically similar to the rebid areas. GAO's analysis found that in 2012, the second year of the round 1 rebid:
The number of beneficiaries furnished DME items included in the CBP generally decreased more in the CBP areas than in the comparator areas. For example, the number of beneficiaries furnished oxygen supplies decreased by about 22 percent in the CBP areas and by about 16 percent in the comparator areas. According to CMS, CBP may have reduced inappropriate usage of DME and these decreases do not necessarily reflect beneficiary access issues. Based on its monitoring tools, which include comparing changes in the health outcomes of beneficiaries in the CBP areas to those in the comparator areas, CMS has concluded that beneficiaries have not been affected adversely by the CBP.
In general, a small number of contract suppliers had a large proportion of the market share in the nine competitive bidding areas. The top four contract suppliers generally accounted for a large proportion of the market in all CBP areas, although the top four suppliers for each product category were not the same in every competitive bidding area. CMS has reported that few contract suppliers had contracts terminated by the agency or voluntarily withdrew from Medicare.
The total number of DME suppliers and Medicare allowed charges decreased more in the CBP areas than in the comparator areas. For example, the number of suppliers in the CBP areas with Medicare allowed charges of $2,500 or more decreased, on average, 27 percent. In the comparator areas, supplier numbers decreased by 5 percent. The decreases in supplier numbers may reflect other factors, such as CMS's efforts to reduce Medicare DME fraud.
The round 1 rebid's first 2 years achieved Medicare cost savings of about $400 million as estimated by CMS, and did not appear to have adversely affected beneficiary access to CBP-covered items. However, with CBP's national mail-order diabetic testing supplies program and expansion into an additional 100 bidding areas in July 2013, it will be important for CMS to continue its efforts to monitor the effects of the CBP.
In commenting on a draft of this report, HHS cited the results of CMS's monitoring of beneficiaries' access to CBP items as evidence that CBP has not adversely affected beneficiaries.

section_title: Letter
paragraphs: In 2012, Medicare—a federal health insurance program—spent   $11.4 billion on durable medical equipment (DME), prosthetics, orthotics,  and related supplies for beneficiaries. The Medicare program is  administered by the Centers for Medicare & Medicaid Services (CMS)  within the Department of Health and Human Services (HHS). Most   which helps pay  Medicare beneficiaries participate in Medicare Part B,for DMEPOS items and supplies, such as oxygen, wheelchairs, hospital  beds, walkers, orthotics, prosthetics, and supplies if they are medically  necessary and prescribed by a physician. Medicare beneficiaries typically  obtain these items from suppliers, which submit claims for payment to  Medicare on behalf of beneficiaries.
To achieve Medicare savings for DMEPOS and to address DMEPOS  fraud concerns, Congress, through the Medicare Prescription Drug,  Improvement, and Modernization Act of 2003, required CMS to phase in  a competitive bidding program (CBP) for DME and other items. Under  CBP, DME suppliers—referred to as contract suppliers—are competitively  selected to furnish certain DME product categories to Medicare  beneficiaries in designated competitive bidding areas. Suppliers not  selected for a CBP contract are referred to as non-contract suppliers.  Non-contract suppliers generally cannot furnish CBP-covered items,  however, some of them may be grandfathered to continue to furnish  some CBP-covered items to certain beneficiaries for a limited time or may  act as subcontractors to contract suppliers.
The  estimated that the round 1 rebid saved Medicare and beneficiaries— through lower coinsurance—about $400 million in its first two years.
In a 2012 report, we reported on the first year—2011—of CBP’s round   1 rebid.had decreased in some CBP product categories, but CMS’s multiple  monitoring activities generally indicated that beneficiary access and  satisfaction had not been affected. You asked us to examine particular  issues concerning the CBP round 1 rebid’s second year—2012. In this  report, we review (1) the extent to which Medicare beneficiaries have  been affected by CBP’s round 1 rebid, (2) the development of contract  suppliers’ market share in CBP’s round 1 rebid, and (3) the extent to  which all suppliers—including both contract and non-contract suppliers— have been affected by CBP’s round 1 rebid.
We found that early data indicated that beneficiary utilization  To examine the extent to which beneficiaries have been affected by the  CBP round 1 rebid, we analyzed changes in utilization of CBP-covered  DME items by comparing Medicare claims data from 2010, the year prior  to the CBP round 1 rebid, to post-CBP round 1 rebid claims data from  2011 and 2012. We used these data to determine whether the number  of CBP-covered beneficiaries utilizing CBP-covered items and services  increased or decreased in each month of 2011 and 2012 compared to the  same month in 2010 for six of the round 1 rebid’s nine product  categories. We did these analyses for Medicare beneficiaries using  CBP-covered items in both the nine competitive bidding areas and in the  nine areas selected by CMS—referred to as comparator areas—in this  report. We also examined how the CBP round 1 rebid may have  affected Medicare beneficiary access to and satisfaction with selected  DME items by analyzing 2011 and 2012 CBP inquiry data from the 1-800- MEDICARE beneficiary help line, and CBP complaint data, and  interviewing CMS officials and officials from a sample of Medicare  beneficiary advocacy groups.
To examine the development of contract suppliers’ market share in the  round 1 rebid, we obtained and analyzed quarterly Medicare claims data  to review contract suppliers’ Medicare market shares in 2011 and 2012  for six of the nine product categories in each competitive bidding area. To  ensure that we captured all Medicare total allowed charges submitted by  a distinct contract supplier that may have been doing business in several  locations under different registered names, national provider identifier  numbers, or provider transaction access numbers, we used the unique  bidder number assigned by CMS to each distinct bidding supplier and  combined all Medicare total allowed charges submitted under any other  identifying numbers for each product category and competitive bidding  area. We then arrayed from highest to lowest all contract suppliers’  individual Medicare total allowed charges for 2011 and 2012 combined  and reviewed the individual market share of the top 4 suppliers for five  product categories as well as the top supplier for the sixth product  category in each competitive bidding area. For each product category in  each competitive bidding area, we also summed all other contract  suppliers’ individual Medicare total allowed charges to show their  combined market share for each quarter of 2011 and 2012. Some  Medicare total allowed charges were submitted by non-contract suppliers.  We identified distinct non-contract suppliers, to the extent possible, by  summing all the Medicare total allowed charges submitted under any  national provider identifier number or provider transaction access number  that were associated with one tax identification number for each product  category in each competitive bidding area. Medicare total allowed  charges submitted by non-contract suppliers were identified by their tax  identification numbers because unique bidder numbers were not  available.
To further determine the extent that contract suppliers may have been  affected by the round 1 rebid, we asked CMS for information on how  many CBP contract suppliers have had their CBP contracts terminated;  have voluntarily withdrawn from Medicare, which results in CMS  canceling their CBP contracts; or have acquired or been acquired by  other DME suppliers. To determine whether there have been changes in  the number of subcontractor suppliers and grandfathered suppliers in  CBP areas,contract suppliers that subcontracted with other suppliers to help fulfill  their CBP contracts, and the extent that grandfathered suppliers were still  furnishing items and services to CBP-covered beneficiaries.   we obtained information from CMS on the number of CBP  To examine the extent to which all suppliers—both contract and non- contract suppliers—may have been affected by the round 1 rebid, we  obtained and analyzed CMS Medicare claims data for the nine  competitive bidding areas and their nine comparator areas. We compared  the number of suppliers with total Medicare allowed charges at two levels  in the 18 areas using the allowed charge data for the third quarter 2010,  and for the third quarter 2012, the comparable quarter in the round   1 rebid’s second year. The third quarter of 2010 was the last one before  the round 1 rebid contract suppliers were announced in November 2010  and before the DME marketplace began to adjust to CBP in the fourth  quarter of 2010. For example, CMS officials told us that some suppliers  furnished diabetic beneficiaries with additional testing supplies in late  2010 before the beneficiaries switched to contract suppliers in 2011. For  this analysis, we included suppliers with at least one allowed charge for a  beneficiary residing in any of the 18 areas for any Medicare DMEPOS  fee-for-service HCPCS codes, excluding the prosthetic and orthotic codes  as this category generally represents more individualized items needing  to be fitted to a beneficiary and including the parenteral—intravenous  nutrition—codes.
To assess the reliability of the data we received from CMS, we reviewed  and identified outliers in the data, and followed up with CMS officials to  clarify and resolve any discrepancies. We assessed the reliability of  Medicare claims data from CMS’s 100 Percent Standard Analytic Files by  reviewing existing information about the data and the systems that  produced them and performing appropriate electronic data checks. We  determined that these data were sufficiently reliable for the purposes of  this report.
We conducted this performance audit from August 2012 through March  2014 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings based on our audit  objectives.
subsections: section_title: Background
paragraphs: Medicare traditionally has paid DMEPOS suppliers through fee schedule  amounts based on suppliers’ historical charges to Medicare. The  purpose of CBP is to improve how Medicare payment amounts are set by  paying only competitively selected contract suppliers amounts based on  competitive bids, thereby providing Medicare program savings and  reducing Medicare beneficiaries’ out-of-pocket expenses for DMEPOS  items and services.
subsections: section_title: The CBP
paragraphs: CMS and its CBP implementation contractor—Palmetto GBA—administer  and implement the CBP and its bidding rounds. In each competitive  bidding area included in a CBP bidding round, suppliers can bid for one or  more product categories’ CBP-covered items.evaluated based on the supplier’s eligibility, financial status, and bid  prices. From this evaluation, the CBP payments—referred to as single  payment amounts—are determined for each CBP-covered item in each   The suppliers’ bids are  competitive bidding area, and the winning suppliers are selected.  Winning suppliers are then offered CBP contracts. If the supplier accepts  its contract offer, it agrees to accept Medicare assignment on the CBP- covered items for the product category and in the competitive bidding  area involved,amounts.   and to be paid the relevant CBP single payment  CMS was also required to take steps to ensure that small suppliers could  be awarded CBP contracts, and accordingly set a target that 30 percent  of the qualified suppliers in each product category in each competitive  bidding area would be small suppliers as defined for CBP. where the small supplier target is not initially met, CMS may award  additional small suppliers CBP contracts after the agency has determined  the number of suppliers needed to meet or exceed CMS’s estimated  beneficiary demand. To help ensure beneficiary access and choice, CMS  tries to award at least five contracts in each product category in each   CMS is required by law to recompete the CBP  competitive bidding area.contracts at least once every three years. (See fig. 1 for CBP’s legislative  history and program implementation timeline.)
For CBP, CMS has defined a small supplier as one that generates gross revenue of  $3.5 million or less in annual receipts including both Medicare and non-Medicare revenue.  A qualified supplier is a bidder that has met certain requirements, including having been  found financially sound, and its bids will be used to determine the single payment amounts  and to select the contract suppliers.
Pub. L. No. 105-33, § 4319(a), 111 Stat. 251, 392-4 (1997) (codified, as amended, at 42 U.S.C.   § 1395w-3).  Pub. L. No. 108-173 § (302)(b), 117 Stat. 2066, 2224-30 (2003) (codified, as amended, at 42 U.S.C.  § 1395w-3). Items and services covered by the competition were durable medical equipment (DME)  and related supplies, off-the-shelf orthotics, and enteral nutrients and related equipment and supplies.
Pub. L. No. 110-275, § 154(a)(2), 122 Stat. 2494, 2560-3 (2008) (codified, as amended, at 42 U.S.C.  § 1395w-3).  The Medicare Improvements for Patients and Providers Act of 2008 and implementing regulations  require CMS to notify suppliers of missing financial documentation if their bids are submitted within  the covered document review date, which is the later of: (1) 30 days before the final date for the close  of the bid window; or (2) 30 days after the bid window opens. For the round 1 rebid, CMS was  required to notify eligible suppliers of missing financial documentation within 45 days after the end of  the covered document review date. For other competitive bidding program (CBP) rounds, CMS is  required to notify eligible suppliers of missing financial documentation within 90 days after the end of  the covered document review date.
The national mail-order competition includes all parts of the United States, including the 50 states,  the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa.
The CBP rounds include:
Round 1 rebid. CMS awarded contracts to 356 contract suppliers   for the provision of DME items and services in nine product categories  in nine competitive bidding areas. The contracts took effect on   January 1, 2011 and expired after three years on December 31, 2013,  except for the mail-order diabetic testing supplies contracts, which  expired on December 31, 2012.
Round 2. Round 2 expands CBP to another 100 competitive bidding  areas in 91 metropolitan statistical areas. The single payment  amounts for covered items were effective July 1, 2013 under round 2  contracts. The round 2 product categories are the same as the round  1 rebid except for the addition of the negative pressure wound therapy  (NPWT) category, the deletion of the complex power wheelchairs  and mail-order diabetic supplies categories, and the extension of the support surfaces category to all round 2 competitive bidding areas.The round 2 contracts are for a term of 3 years.
National mail-order diabetic testing supplies program. The CBP  national mail-order diabetic testing supplies program competition was  conducted at the same time as round 2, and its competitively  determined single payment amounts were effective July 1, 2013.
Unlike in the round 1 rebid, suppliers bidding for the national program  had to demonstrate that their bids would cover at least 50 percent, by  sales volume, of all types of diabetic testing strips on the market.  These contracts are for a term of 3 years. Non-mail order Medicare  payments are the same as the mail-order single payment amounts for  the CBP-covered items.
Round 1 recompete. In anticipation of the expiration of the round 1  rebid contracts, in 2012 CMS recompeted contracts for the nine round  1 rebid competitive bidding areas, referred to as the round 1  recompete. The round 1 recompete’s six product categories differ  from the round 1 rebid categories by adding infusion pumps, NPWT  pumps, deleting complex wheelchairs, and creating a new category  that includes home equipment, such as hospital beds and commode  chairs. The recompete contracts have a 3-year term, with an  effective date of January 1, 2014.
section_title: CBP Contract Supplier Terminations, Voluntary Withdrawals, and Changes in Ownership
paragraphs: A contract supplier may no longer participate in CBP if CMS terminates its  contract, if it voluntarily withdraws from Medicare, or if it has experienced  a certain type of change of ownership. CMS can terminate a contract  supplier’s CBP contract if a supplier fails to meet its contractual  obligations. In that case, CMS may request that the supplier submit a  corrective action plan, suspend or terminate the contract, preclude it from  participating in CBP, or revoke its billing number. A contract supplier that  has its CBP contract terminated may continue to operate as a Medicare  supplier and submit Medicare claims for non-CBP covered items and  services. Contract suppliers may choose to voluntarily withdraw from  Medicare, and thus no longer be a Medicare supplier. Contract suppliers  may also have a change in ownership that impacts their participation in  CBP, but their CBP contracts may be transferred only under certain  circumstances. A change in ownership, also referred to as a CHOW, may  result in either (1) a new entity or company that did not exist before the  merger or acquisition transaction; or (2) a successor entity or company  that exists before the transaction, merges or acquires a contract supplier,  and continues to exist as it did before the transaction. If a contract  supplier is negotiating an ownership change, the supplier must notify  CMS in advance and CMS may award the CBP contract to the entity that  merges with or acquires the contract supplier in certain circumstances.  These circumstances include when the successor entity is acquiring the  assets of the contract supplier and submits a signed agreement to CMS  in advance of the acquisition stating that it will assume all obligations  under the contract.
section_title: Beneficiary Sources for CBP Assistance
paragraphs: Medicare beneficiaries residing in competitive bidding areas have several  sources available to help them locate contract suppliers and receive  assistance for CBP-related issues.
CBP Online Contract Supplier Locator. To locate a CBP contract  supplier, beneficiaries can use the CMS online supplier locator tool on  CMS’s Medicare website. The contract locator tool contains the  names of the contract suppliers in each competitive bidding area, as  well as the product categories for which they furnish CBP-covered  items. Contract suppliers are responsible for submitting information  regarding the specific brands of items they furnish in the upcoming  quarter, and CMS uses this information to update the supplier locator.
1-800-MEDICARE Inquiries. CMS has directed beneficiaries to call  its 1-800-MEDICARE beneficiary help line with CBP questions— referred to by CMS as inquiries. Callers are assisted by trained CBP  customer service representatives (CSR) who use several scripts to  answer general questions about CBP and specific product categories  and assist beneficiaries in finding CBP suppliers. If a beneficiary’s  inquiry cannot be addressed by the scripts, the CSR will forward the  inquiry to an advanced-level CSR who will research the issue and  respond to the beneficiary’s inquiry.
Palmetto GBA and CMS regional offices. Palmetto GBA, the CBP  implementation contractor, investigates all beneficiary or supplier  complaints related to alleged CBP contract violations. In addition,  Palmetto GBA provides CBP-related information and updates through  its website. Local Palmetto GBA staff are stationed in the  competitive bidding areas and work with CMS regional staff to monitor  CBP activities and identify and address any emerging issues. CMS  also uses its regional offices as the focal point for calls that cannot be  resolved by 1-800-MEDICARE; for example, the offices may assist  when a CSR is unable to help a beneficiary find a contract supplier.
Competitive Acquisition Ombudsman (CAO). The CMS CAO was  created to respond to CBP-related complaints and inquiries made by  suppliers and individuals, and works with CMS officials and  contractors and Palmetto GBA to resolve them. The CAO is required  to submit an annual report detailing CBP-related activities to  Congress.
section_title: CMS’s CBP Monitoring Activities
paragraphs: CMS has implemented several activities to monitor whether beneficiary  access or satisfaction have been affected by the implementation of CBP.
Inquiries and Complaints to 1-800-MEDICARE. CMS tracks all  CBP-related inquiries to 1-800-MEDICARE. All calls are first classified  as inquiries and CMS defines as a CBP complaint only those inquiries  that cannot be resolved by any 1-800-MEDICARE CSR and is  elevated to another entity, such as Palmetto GBA, CMS’s regional  offices, or the CAO for resolution.
Beneficiary Satisfaction Surveys. CMS conducted pre and post- implementation surveys to measure beneficiary satisfaction with  CBP’s round 1 rebid. The pre-implementation survey was conducted  from June to August 2010, the first post-implementation survey was  conducted from August to October 2011, and the second post- implementation survey was conducted in June 2013. CMS surveyed  beneficiaries in the nine round 1 rebid competitive bidding areas, as  well as the nine comparator areas.
National Claims History. CMS conducts daily monitoring of national  Medicare claims data to identify utilization trends, monitor beneficiary  access, address aberrations in services, and target potential fraud  and abuse. CMS tracks health outcomes—such as hospitalizations,  emergency room visits, physician visits, admissions to skilled nursing  facilities, and deaths—for beneficiaries likely to use a CBP-covered  product and who have used a CBP-covered product, in both  competitive bidding areas and comparator areas to determine whether  health outcomes in the competitive bidding areas remain consistent  with national trends. CMS posts quarterly reports of these health  outcomes on its website.
Form C. Each quarter, CMS requires contract suppliers to submit a  Form C that lists the specific CBP-covered DME items they plan to  furnish the following quarter—including the brand names and  equipment models. According to Palmetto GBA, this information is used to update the Medicare supplier directory tool and to evaluate  beneficiary access to competitively bid items, as well as the quality of  items and services.
Secret shopping. CMS has conducted secret shopping calls in which  individuals posed as beneficiaries and requested items, such as  specific diabetic supplies from contract suppliers to determine whether  the suppliers offer the supplies they claim to furnish. Secret shopping  is conducted on a limited ad-hoc basis and may be done in response  to specific complaints received, or to evaluate certain contract  suppliers and monitor their performance and compliance with the  terms of their CBP contracts.
section_title: Medicare Claims Data Show Larger Decreases in Beneficiary Utilization in Competitive Bidding Areas than Comparator Areas, but Beneficiary Access Does Not Appear to Have Been Affected
paragraphs: Our analysis of Medicare claims data found that for five of the six product  categories we examined, the number of distinct beneficiaries furnished  CBP-covered items generally decreased more in the competitive bidding  areas than in the comparator areas in each month of 2011 and 2012  compared to the same month of 2010. CMS continued several ongoing  monitoring activities and reported that the CBP round 1 rebid did not  affect beneficiary access and satisfaction in its second year. In addition,  several Medicare beneficiary advocacy groups that we interviewed did not  report widespread access issues among their members.
subsections: section_title: Medicare Claims Data Show Larger Decreases in Beneficiary Utilization in Competitive Bidding Areas than Comparator Areas
paragraphs: Our analysis of Medicare claims data found that the number of distinct  beneficiaries furnished CBP-covered items generally decreased more in  the nine competitive bidding areas than in the nine comparator areas in  each month of 2011 and 2012 compared to the same month of 2010 for  five of the six product categories we analyzed. However, the larger  decreases in the number of beneficiaries furnished CBP-covered items in  the competitive bidding areas do not necessarily indicate that CBP- covered beneficiaries did not receive needed DME. As CMS has  reported, the CBP may have curbed previous inappropriate distribution of  some CBP-covered items in competitive bidding areas.
subsections: section_title: Enteral Product Category
paragraphs: Our analysis found that fewer beneficiaries received one or more enteral  product category items in each month of 2011 and 2012 compared to the  same month of 2010. In 2012, the declines were roughly equivalent in the  competitive bidding areas and the comparator areas. (See fig. 2.) For  example, in the competitive bidding areas, the number of CBP-covered  beneficiaries who received one or more items in May 2012 decreased by  about 4 percent compared to May 2010. In the comparator areas, the  number of beneficiaries who received one or more items was about   6 percent lower in May 2012 compared to May 2010.
Our analysis found that fewer beneficiaries received one or more hospital  bed product category items in all months of 2011 and 2012 compared to  the same month of 2010 in the competitive bidding areas, with  consistently lesser declines in the comparator areas over the same  period. (See fig 3.)
Our analysis of Medicare claims data found that the number of  beneficiaries who received one or more oxygen product category items  each month of 2011 and 2012 compared to the same month of 2010  decreased more in the competitive bidding areas than in the comparator  areas, although there were substantial declines in both types of areas.  (See fig. 4.) For example, compared to May 2010, the number of  beneficiaries furnished one or more oxygen product category items  decreased by about 9 percent in May 2011 and by about 22 percent in  May 2012 in the competitive bidding areas. For the comparator areas, the  number of beneficiaries furnished one or more items decreased by about   5 percent in May 2011 and by about 16 percent in May 2012.
Our analysis found that substantially fewer beneficiaries in the  competitive bidding areas received one or more walkers product category  items in each month of 2011 and 2012 compared to the same month of  2010, although there were also declines in the comparator areas. (See  fig. 5.) For example, compared to May 2010, the number of CBP-covered  beneficiaries who received one or more walkers product category items  was about 26 percent lower in May 2011 and about 24 percent lower in  May 2012. In the comparator areas, compared to May 2010, 6 percent  fewer beneficiaries received one or more walkers product category items  in May 2011 and about 5 percent fewer beneficiaries received one or  more of these items in May 2012.
We found that fewer beneficiaries in the competitive bidding areas  received one or more standard power wheelchair product category items  each month of 2011 and 2012 compared to the same month of 2010.  (See fig. 6.) For example, compared to May 2010, about 16 percent fewer  beneficiaries in the competitive bidding areas received one or more  standard power wheelchair product category items in May 2011 and  about 15 percent fewer in May 2012. We did not include like information  for the comparator areas because CMS changed the payment policy for  standard power wheelchairs in non-competitive bidding areas only,  making a comparison to the competitive bidding areas difficult. This  change in payment policy, which was effective January 1, 2011,  eliminated the option for the lump sum purchase payment for standard  power wheelchairs in all non-competitive bidding areas.
section_title: CMS Reports that Its Ongoing Monitoring Tools Indicate that CBP’s Round 1 Rebid Has Not Affected Beneficiary Access and Satisfaction
paragraphs: As it did in 2011, CMS continued several ongoing activities to monitor  CBP’s effects on beneficiaries in 2012. CMS’s activities included  monitoring the number of CBP-related inquiries and complaints made to  1-800-MEDICARE and the health outcomes of CBP-covered beneficiaries  in competitive bidding areas. CMS reported that the implementation of the  CBP round 1 rebid did not result in beneficiary access issues in the first  two years of the program. In addition, representatives of several Medicare  beneficiary advocacy groups that we interviewed did not report that  widespread access issues occurred.
subsections: section_title: Total Number of Inquiries and Complaints Significantly Decreased in CBP’s Second Year
paragraphs: According to data provided by CMS, 1-800-MEDICARE received a total of  44,249 CBP-related questions—referred to by CMS as inquiries—in 2012,  which was fewer than the 127,466 CBP-related inquiries reported in 2011.  The total number of quarterly CBP-related inquiries to 1-800-MEDICARE  ranged from a high of 56,941 in the first quarter of 2011 (17,672 product- related inquiries plus 39,269 general CBP inquiries) to a low of 7,969 in  the fourth quarter of 2012 (4,119 product-related inquiries plus 3,850  general CBP inquiries). (See fig. 8.) The majority of total inquiries for both  2011 and 2012 were general in nature; for example, CMS officials told us  that inquiries were related to questions about the program or finding a  contract supplier. About 2 million beneficiaries reside in CBP round 1  rebid competitive bidding areas; the ratio of inquiries to 1-800-MEDICARE  compared with CBP beneficiaries is approximately 1 inquiry for every 45  beneficiaries.
As was also the case in 2011, CMS data showed that the majority of all  CBP product-category specific inquiries to 1-800-MEDICARE—over  13,000 in 2012—were related to mail-order diabetic supplies. The enteral  product category and support surfaces product category received the  fewest number of inquiries. (See fig. 9.)
All calls to 1-800-MEDICARE are initially classified as inquiries and only  recorded as complaints if they cannot be resolved by a CSR. In 2012,  CMS classified 43 CBP-related calls to 1-800-MEDICARE as complaints,  which was a decline from 151 complaints in 2011. Among the 43  complaints, 13 complaints were specific to the walkers product category,  which was almost more than twice the number of complaints associated  with any of the other product categories. Twelve of the 13 complaints  were related to a specific walker brand and model that can be billed under  HCPCS code E0147, which has the highest single payment amount of all  CBP-covered HCPCS codes included in the walkers product category.  Some complainants reported that contract suppliers would not provide the  specific walker brand and model prescribed by beneficiaries’ physicians  because the CBP single payment amount is lower than the cost of the  item. According to Palmetto GBA data, in response to one complaint, it  conducted secret shopping calls to two contract suppliers and was told by  both that they did not carry the specific walker brand and model and could  not obtain it. After Palmetto GBA explained the terms of their contracts,  both contract suppliers then agreed to provide it. Half of these 12  complaints originated in the Miami competitive bidding area, where there  was a decline in utilization for these walkers.
section_title: CMS Has Several Other Monitoring Efforts to Conduct CBP Program Oversight
paragraphs: According to CMS, the agency continues to monitor national Medicare  claims data to identify utilization trends, monitor health outcomes and  beneficiary access, address aberrations in services, and target potential  fraud and abuse. As part of this effort, CMS monitors a range of health  outcomes—including deaths, hospitalizations, emergency room visits,  physician visits, and admissions to skilled nursing facilities—for  beneficiaries likely to use a CBP-covered item or who have used a CBP- covered item, in both competitive bidding areas and their comparator  areas. In both 2011 and 2012, CMS’s monitoring of health outcomes from  national claims data indicated that CBP-covered beneficiaries continued  to have access to necessary and appropriate CBP-covered items and  supplies, and that health outcomes in the competitive bidding areas were  consistent with national trends. However, as we previously reported,while these outcomes are reassuring, they may not reflect other  outcomes that did not require physician, hospital, or emergency room  visits, such as whether beneficiaries received the DME item they needed  on time, or whether health outcomes were caused by problems accessing  CBP-covered DME.
CMS data show that the agency monitored beneficiary access by  conducting more secret shopping calls in 2012 than it did in 2011—300  versus 32. According to that data, the highest number of secret shopping  calls in 2012 involved the oxygen product category (109) and the second  highest number of calls involved the walker product category (58).  According to CMS officials, secret shopping calls were prompted by  beneficiary and industry concerns expressed to CMS. For example, CMS  officials told us that the agency received complaints that contract  suppliers were not providing liquid oxygen equipment and specific walker  models. According to these officials, when conducting secret shopper  calls, CMS provides contract suppliers additional education on  competitive bidding program and supplier quality standard requirements.  CMS then conducts subsequent secret shopper calls to verify that the  contract suppliers are adhering to the requirements.
CMS conducted a pre-CBP implementation survey in 2010 and post-CBP  implementation survey in 2011 to measure beneficiary satisfaction with  the CBP round 1 rebid’s first year. According to CMS data, the agency  obtained responses from at least 400 beneficiaries in each of the nine  competitive bidding areas and nine comparator areas to collect  beneficiary satisfaction ratings for six questions related to the  beneficiary’s initial interaction with DME suppliers, the training received  regarding DME items, the delivery of the DME item, the quality of service  provided by the supplier, the customer service provided by the supplier,  and the supplier’s overall complaint handling. According to CMS data,  results of the pre-2010 and post-CBP 2011 implementation surveys  showed that responses from beneficiaries were similar and generally  positive in both the competitive bidding areas and comparator areas.CMS officials told us that CMS conducted a follow-up beneficiary  satisfaction survey in June 2013 using the original survey questions and  methodology, but as of November 20, 2013, survey results were not yet  available.
section_title: Beneficiary Advocacy Groups We Interviewed Did Not Report Widespread CBP Beneficiary Access Concerns
paragraphs: We interviewed representatives from several beneficiary advocacy groups  about their members’ experiences with CBP, and whether they were  aware of any CBP-related beneficiary access and choice issues that may  have occurred among their members. The beneficiary groups represent  beneficiaries with specific issues, such as those with diabetes and  disabilities requiring wheelchairs. In general, these representatives either  reported no or few concerns, or provided anecdotal examples of  beneficiary access issues, such as difficulty obtaining wheelchair repairs,  or difficulty locating contract suppliers. They did not indicate that their  CBP-covered beneficiary members had been negatively affected by  widespread access issues or concerns in the first two years of the CBP  round 1 rebid.
section_title: For the Round 1 Rebid Product Categories and Areas, a Small Number of Contract Suppliers Accounted for a Large Portion of the CBP Market Share in 2011 and 2012
paragraphs: For the round 1 rebid product categories we examined, a small number of  contract suppliers accounted for a large portion of Medicare total allowed  charges across 2011 and 2012. One contract supplier had a high  percentage of the total market share for the standard power wheelchair  product category across 2011 and 2012, but was terminated as a contract  supplier in 2013. Few contract suppliers left the CBP through contract  terminations, voluntarily withdrawing from Medicare, or having had a  change in ownership.
subsections: section_title: A Small Number of Contract Suppliers Accounted for a Large Portion of the Market Share
paragraphs: We examined the contract supplier market share development for six  product categories in 2011 and 2012 and found that the trends for each  product category were relatively consistent across the nine competitive  bidding areas. For each product category, we illustrate typical market  share development trends by showing examples from two competitive  bidding areas. (See fig. 10 through fig. 21.) For five of the six product  categories, we found that, in general, the top 4 suppliers—those with the  highest individual Medicare total allowed charges across all quarters of  2011 and 2012—accounted for a large portion of the market in all  competitive bidding areas, although the top 4 suppliers for each product   In our examples, the  category could vary by competitive bidding area.top 4 suppliers’ combined market share in the fourth quarter of 2012  ranged from 50 percent for the enteral product category in the Dallas  competitive bidding area to 86 percent for the walkers product category in  the Orlando competitive bidding area.
subsections: section_title: CPAP/RAD Product Category
paragraphs: Our analysis of Medicare claims data for the CPAP/RAD product category  indicates that, in general, the market share among the top 4 contract  suppliers increased steadily, the combined market share for the other  contract suppliers’ remained relatively consistent with some small  increases, and the non-contract suppliers’ combined market share  decreased throughout 2011 and 2012. For example, in the Pittsburgh  competitive bidding area, by the fourth quarter of 2012, the top 4 contract  suppliers combined had about 63 percent of the market, while the other  10 contract suppliers combined had 35 percent of the market. (See   fig. 10.) This is fairly similar to the contract supplier market share trend in  the Cleveland competitive bidding area, where the top 4 contract  suppliers combined had about 73 percent of the market and the other   8 contract suppliers combined had about 26 percent in the fourth quarter  of 2012. (See fig. 11.)
Our analysis of Medicare claims data for the enteral product category  indicates that, in general, the market share of the top 4 contract suppliers  and all other contract suppliers combined remained relatively consistent  or increased throughout 2011 and 2012. For example, in the Cincinnati  competitive bidding area, the top 4 contract suppliers combined had  about 70 percent or more of the market share throughout 2011 and  2012. For that same time period, the other 10 contract suppliers  combined generally had about 20 percent of the market in that area. (See  fig. 12.) In the Dallas competitive bidding area, the top 4 contract  suppliers combined had less of the market share—between about 43 to  55 percent each quarter of 2011 and 2012—while the other 20 contract  suppliers had more of the market share each quarter. (See fig. 13.)
Our analysis of Medicare claims data for the hospital bed product  category indicates that contract suppliers’ percentages of Medicare total  allowed charges increased steadily throughout 2011 and 2012 as non- contract suppliers’ percentages of Medicare total allowed charges  substantially decreased. In both the Riverside and Orlando competitive  bidding areas, the top 4 contract suppliers accounted for more than   80 percent of the market by the fourth quarter of 2012, with the other  contract suppliers totaling about 10 percent of Medicare total allowed  charges in each of the areas. (See fig.14 and fig. 15.)
Our analysis of Medicare claims data for the oxygen product category  indicates that the market share of the top 4 contract suppliers and all  other contract suppliers combined remained relatively consistent or  increased from the first quarter of 2011 to the fourth quarter of 2012. For  example, in the Cleveland competitive bidding area, the top 4 suppliers  had about 65 percent of the market in the first quarter of 2011 and about  71 percent of the market in the fourth quarter of 2012. (See fig. 16.) In the  Kansas City competitive bidding area, the top 4 suppliers had about   71 percent of the market in the first quarter of 2011 and about 83 percent  of the market in the fourth quarter of 2012. (See fig. 17.)
Our analysis of Medicare claims data for the walkers product category  indicates that the market share of the top 4 contract suppliers and all  other contract suppliers combined remained relatively consistent  throughout 2011 and 2012. For example, in the Pittsburgh competitive  bidding area, the top 4 contract suppliers combined had at least   65 percent of the total market share each quarter of 2011 and 2012. The  other 11 contract suppliers combined had between about 20 to 30 percent  of the market share each quarter over that time period. (See fig. 18.) The  Orlando competitive bidding area showed a similar market share trend  where the top 4 contract suppliers combined maintained at least   72 percent of the total market share each quarter of 2011 and 2012. The  other 13 contract suppliers combined consistently had about 20 percent  each quarter. (See fig. 19.)
Our analysis of Medicare claims data for the standard power wheelchair  product category indicates that the market share for the top contract  supplier, The Scooter Store’s Alliance Seating & Mobility Division (The  Scooter Store), was very high in all quarters of 2011 and 2012 across all  competitive bidding areas. Specifically, The Scooter Store had the highest  individual supplier percent of all CBP-covered Medicare total allowed  charges across all quarters of 2011 and 2012 combined for the standard  power wheelchair product category in eight of the nine competitive  bidding areas, and the second highest in the ninth competitive bidding  area. The Scooter Store’s individual percentages of all Medicare total  allowed charges in the fourth quarter of 2012 were: Pittsburgh   (82 percent), Orlando (81 percent), Miami (75 percent), Riverside   (72 percent), Cleveland (62 percent), Dallas (60 percent), Charlotte   (48 percent), Kansas City (41 percent), and Cincinnati (37 percent).
In the Miami competitive bidding area, Medicare claims data show that  The Scooter Store’s highest individual percentage of all Medicare total  allowed charges was about 84 percent in the second quarter of 2011.  (See fig. 20.) In the Riverside competitive bidding area, The Scooter  Store’s highest individual percentage of all Medicare total allowed  charges was about 72 percent in the fourth quarter of 2012. (See fig. 21.)
section_title: Round 1 Rebid’s Top Standard Power Wheelchair Contract Supplier in 2011 and 2012 Was Terminated in 2013
paragraphs: In September 2013, CMS issued a termination notice, with an effective  date of October 26, 2013, for The Scooter Store’s CBP round 1 rebid  contract in all competitive bidding areas. Prior to issuing the termination  notice, CMS removed all references to both The Scooter Store and its  Alliance Seating & Mobility Division from all CBP round 1 rebid contract  supplier lists on its website in March 2013. A CMS official told us that the  removal occurred because of compliance issues identified with The  Scooter Store’s round 1 rebid contract and that CMS began initiating the  contract termination process at that time. According to CMS, it carefully  scrutinizes CBP bidders to ensure that only qualified suppliers are  selected to participate in the program; however, The Scooter Store had  been the subject of allegations of fraud prior to being awarded a contract  in both CBP’s round 1 and round 1 rebid. Specifically, in 2007, The  Scooter Store entered into a civil settlement agreement with the U.S.  Government to resolve several lawsuits and agreed to pay $4 million and  relinquish its right to receive reimbursement for pending Medicare  claims.violated the civil False Claims Act and defrauded the United States by,  among other things, enticing some beneficiaries to obtain power scooters  covered by Medicare and Medicaid and then supplying more costly power  wheelchairs that beneficiaries did not want, did not need, or could not  use.
In one of the lawsuits, the Government alleged that the company  Although too soon to determine the full effects, The Scooter Store’s 2013  termination as a contract supplier could potentially result in access issues  for beneficiaries residing in the CBP round 1 rebid competitive bidding  areas. For example, one round 1 rebid contract supplier we interviewed  told us that her company received calls from some of The Scooter Store’s  beneficiaries seeking wheelchair repairs. However, this contract supplier  and two others told us that some contract suppliers are reluctant or  unwilling to repair a wheelchair that they did not originally provide  because if the contract suppliers did the repairs, and CMS later  determined that The Scooter Store had furnished a wheelchair that did  not meet documentation requirements, CMS could recover payments  made to the repairing contract suppliers.
section_title: Few Contract Suppliers Left the Competitive Bidding Program in its First Two Years
paragraphs: In the round 1 rebid’s second year, a few contract suppliers—8 percent— had their contracts terminated by CMS or voluntarily withdrew from  Medicare, and some had an ownership change. Contract suppliers  continued to use subcontractors to provide certain services to  beneficiaries in the round 1 rebid competitive bidding areas, but no new  agreements were disclosed in 2012. The number of grandfathered  suppliers decreased in 2012 to the point that CMS discontinued its  monitoring as rental agreements expired.
subsections: section_title: In CBP’s First Two Years, About 8 Percent of Contract Suppliers Had Contracts Terminated or Voluntarily Withdrew From Medicare
paragraphs: By the end of the CBP’s second year, 27 of the original 356 contract  suppliers—about 8 percent—had been terminated by CMS or had  voluntarily withdrawn from Medicare, according to CMS data. Eleven  contract suppliers were terminated—4 in 2012 and 7 in 2011. Nine  terminated suppliers were small suppliers as defined for CBP. One  terminated supplier was not experienced in one of its competitive bidding  areas; all were experienced in their product categories. The 11 terminated  contract suppliers had a total of 22 round 1 rebid product category and  competitive bidding area combinations. (See table 1.) The oxygen product  category and the Miami competitive bidding area were the most affected.
Sixteen contract suppliers withdrew voluntarily from Medicare, 7 in 2012  and 9 in 2011. Of these 16 withdrawn suppliers, 13 were small suppliers.  Two suppliers that withdrew had no experience in 1 of their product  categories; and all 16 were experienced in their competitive bidding  areas. The 16 suppliers that withdrew had a total of 37 round 1 rebid  product category and competitive bidding area combinations. (See   table 2.) The oxygen product category and the Miami competitive bidding  area were the most affected.
During the round 1 rebid’s first two years, 12 of the original 356 round 1  rebid contract suppliers—3 percent—had a change in ownership. (See  table 3.) For 11 of the 12 changes, CMS awarded the round 1 rebid  contracts to the acquiring entity as the entity assumed the obligations  under these contracts. In 2012, the only ownership change involved a  contract supplier that purchased another contract supplier, but did not  assume the purchased supplier’s CBP contracts. In this ownership  change, the purchasing contract supplier already had CBP contracts in  the same competitive bidding areas for the same product categories, and  began serving the purchased contract supplier’s Medicare beneficiaries  including its grandfathered beneficiaries.
section_title: Contract Suppliers Did Not Enter Into New Subcontracting Agreements, and Grandfathered Suppliers Continued to Decrease
paragraphs: While contract suppliers have continued to use subcontractor suppliers to  assist them in furnishing items to CBP-covered beneficiaries, CMS  officials told us no contract suppliers disclosed any new subcontracting  agreements in 2012 or during the first three months of 2013. As of April  2013, CMS data indicated that 116 distinct contract suppliers have had at  least one subcontracting agreement; in total, there were 730 agreements  involving 228 distinct subcontractor suppliers. Forty-seven percent (55) of  the 116 contract suppliers had one subcontract agreement. The other 61  contract suppliers had multiple subcontracts, including one contract  supplier with 50 agreements. Eight of the 116 contract suppliers had  subcontract agreements that ended in 2011, 2012, or early 2013.
CMS officials also told us that the number of grandfathered suppliers had  so diminished that the agency was no longer monitoring them after the  second quarter 2012. As we previously reported, the number of  grandfathered suppliers had declined steadily during the rebid’s first year  (2011); in December 2011, 22 percent (575 of 2,594) of the grandfathered  suppliers were still billing Medicare for CBP-covered beneficiaries they  had at the end of December 2010, the year before the CBP began.
section_title: The Number of Suppliers and Their Medicare Allowed Charges Generally Decreased More in Competitive Bidding Areas than in Comparator Areas
paragraphs: Comparing the third quarters of 2010, before the rebid began, and 2012,  the rebid’s second year, both the number of suppliers and their Medicare  allowed charges generally decreased more in the competitive bidding  areas than in the comparator areas. (See app. I.) The number of  suppliers with Medicare allowed charge amounts of $2,500 or more per  quarter decreased an average of 27 percent in the competitive bidding  areas, and 5 percent in the comparator areas. (See table 4.) All nine  competitive bidding areas and six of the nine comparator areas  experienced decreases in those supplier numbers. The Miami competitive  bidding area experienced the greatest change in suppliers—decreasing  by 227 suppliers—a 32 percent change. The number of large suppliers,  which we define as having quarterly allowed Medicare charges of  $100,000 or more, decreased an average of 18 percent in the competitive  bidding areas, while there was essentially no change in the average  number of large suppliers in the comparator areas. All nine competitive  bidding areas and three of the nine comparator areas had decreases in  these large suppliers. The Cincinnati competitive bidding area had the  greatest percentage decrease in suppliers at this level—32 percent.
The total Medicare allowed charges for the same time period also  decreased for all nine competitive bidding areas and all nine comparator  areas. (See app. II.) The average decrease for the competitive bidding  areas was 28 percent, and 7 percent for the comparator areas. (See   table 5.) There were three competitive bidding areas with the highest total  charge decrease of 32 percent, including for example, the Cincinnati  area’s charges that decreased about $4.2 million from third quarter 2010   ($12.9 million) to third quarter 2012 ($8.7 million). The Orlando  competitive bidding area had the lowest percentage decrease change— 22 percent—a decrease in total charges of about $3.3 million. Among the  comparator areas, the highest total charge decrease was San Diego—  15 percent—a decrease of about $2 million (from $13.7 million to   $11.6 million), while Virginia Beach had the lowest decrease—  0.1 percent—or $17,077 (from $12,603,542 to $12,586,465).
section_title: Concluding Observations
paragraphs: The CBP round 1 rebid’s savings for both the Medicare program and the  rebid-covered beneficiaries continued in the second year, with CMS  reporting total savings of more than $400 million in the rebid’s first two  years due to its lower payments, decreased utilization, and lower  beneficiary coinsurance. In the rebid’s second year, beneficiary utilization  of CBP-covered DME items continued to decrease—more in the rebid’s  competitive bidding areas than the comparator areas. CMS’s monitoring  activities, however, did not indicate beneficiary access issues. As we  reported in 2012, we do not assume that all pre-CBP utilization was  appropriate, and CBP may be continuing to reduce unnecessary  utilization. CMS’s fraud prevention efforts may also be affecting DME  utilization.
Continued monitoring of CBP experience is important to determine the full  effects it may have on Medicare beneficiaries and DME suppliers. It will  be important to determine whether the DME utilization trends in the   round 1 rebid’s first two years are similar to those in CBP’s other rounds.  With the CBP’s 3-year round 1 rebid complete, the CBP’s 2013 round 2  expansion into an additional 100 competitive bidding areas, the 2013  implementation of the national mail-order diabetic testing supplies  program, and the 2013 selection of the new contract suppliers in the  original nine areas for the next 3-year contracts beginning in 2014,  significant new data will soon be available to further assess the impact of  the program.
section_title: Agency Comments and Our Evaluation
paragraphs: HHS reviewed a draft of this report and provided written comments which  are reprinted in appendix III. HHS also provided technical comments,  which we incorporated as appropriate. In its general comments, HHS  stated that CMS will continue monitoring the CBP to ensure Medicare  beneficiaries are not adversely affected by the program, including  continuing to use its real-time claims monitoring system. The monitoring  activities are important as the CBP has expanded to include 100  additional competitive bidding areas and a national mail-order program for  diabetic testing supplies. HHS also stated that it anticipates CBP will  provide substantial savings for both the Medicare Part B Trust Fund and  Medicare beneficiaries.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of Health and Human Services and appropriate congressional  committees. The report will also be available at no charge on our website  at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix IV.
section_title: Appendix I: Number of Suppliers in the Round 1 Rebid Competitive Bidding Areas and Their Comparator Areas; 2010 and 2012
subsections: section_title: Number of suppliers with $2,500 or more in
section_title: Number of suppliers with $2,500 or more in
section_title: Appendix II: Medicare Allowed Charges for Round 1 Rebid Competitive Bidding Areas and Their Comparator Areas; 2010 and 2012
subsections: section_title: Round 1 rebid competitive bidding areas and their comparator areas 1 Charlotte Virginia Beach comparator
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this report  were Martin T. Gahart, Assistant Director; Yesook Merrill, Assistant  Director; Todd Anderson; Dan Lee; Drew Long; Michelle Paluga;   Hemi Tewarson; and Opal Winebrenner.
section_title: Related GAO Products
paragraphs: Medicare: Review of the First Year of CMS’s Durable Medical Equipment  Competitive Bidding Program’s Round 1 Rebid. GAO-12-693.  Washington, D.C.: May 9, 2012.
Medicare: The First Year of the Durable Medical Equipment Competitive  Bidding Program Round 1 Rebid. GAO-12-733T. Washington, D.C.:   May 9, 2012.
Medicare: Issues for Manufacturer-level Competitive Bidding for Durable  Medical Equipment. GAO-11-337R. Washington, D.C.: May 31, 2011.
Medicare: CMS Has Addressed Some Implementation Problems from  Round 1 of the Durable Medical Equipment Competitive Bidding Program  for the Round 1 Rebid. GAO-10-1057T. Washington, D.C.: Sept. 15,  2010.
Medicare: CMS Working to Address Problems from Round 1 of the  Durable Medical Equipment Competitive Bidding Program. GAO-10-27.  Washington, D.C.: Nov. 6, 2009.
Medicare: Covert Testing Exposes Weaknesses in the Durable Medical  Equipment Supplier Screening Process. GAO-08-955. Washington, D.C.:  July 3, 2008.
Medicare: Competitive Bidding for Medical Equipment and Supplies  Could Reduce Program Payments, but Adequate Oversight Is Critical.  GAO-08-767T. Washington, D.C.: May 6, 2008.
Medicare: Improvements Needed to Address Improper Payments for  Medical Equipment and Supplies. GAO-07-59. Washington, D.C.:   Jan. 31, 2007.
Medicare Payment: CMS Methodology Adequate to Estimate National  Error Rate. GAO-06-300. Washington, D.C.: March 24, 2006.
Medicare Durable Medical Equipment: Class III Devices Do Not Warrant  a Distinct Annual Payment Update. GAO-06-62. Washington, D.C.:   March 1, 2006.
Medicare: More Effective Screening and Stronger Enrollment Standards  Needed for Medical Equipment Suppliers. GAO-05-656. Washington,  D.C.: Sept. 22, 2005.
Medicare: CMS’s Program Safeguards Did Not Deter Growth in Spending  for Power Wheelchairs. GAO-05-43. Washington, D.C.: Nov. 17, 2004.
Medicare: Past Experience Can Guide Future Competitive Bidding for  Medical Equipment and Supplies. GAO-04-765. Washington, D.C.:   Sept. 7, 2004.
Medicare: CMS Did Not Control Rising Power Wheelchair Spending.  GAO-04-716T. Washington, D.C.: April 28, 2004.