BALTIMORE--CMS paid more than $21 million in improper claims for negative wound therapy pumps and accessories in 2004, the Office of Inspector General said in a report released Monday.

The OIG reviewed payments for the pumps after claims shot up by 444 percent between 2001 and 2005, from $25 million to $136 million.

In its report, "Medicare Payments for Negative Pressure Wound Therapy Pumps," the OIG found that nearly a quarter of all the 2004 claims did not meet Medicare requirements. Most of the improper claims had insufficient documentation, the report said. For 44 percent of the claims, supplier-prepared statements were not fully supported by patients' medical records, the OIG said.

The review was based on a random sample of 378 pump claims from CMS' National Claims History file with dates of service in 2004.

While the DMERCs had some safeguards in place to prevent improper payments, they were different among the four contractors, the OIG found.

Based on its review, the OIG recommended that CMS conduct additional medical reviews of claims for the pumps and look at medical records instead of only supplier-prepared statements. CMS should also educate suppliers and wound care providers about use of the pumps and the documentation necessary for medical records, the OIG said.

The OIG further recommended that CMS:

• consider establishing advance coverage determinations for pump claims from suppliers with a high number of claims for the equipment or who have been denied or have a pattern of overuse.
• require face-to-face exams of patients, or require suppliers to get certain parts of patients' medical records from physicians to support the medical necessity of the pumps.
• consider strengthening coverage criteria for the pumps and increase prepayment reviews of claims for them.

CMS said it agreed with some of the OIG's recommendations: making claims reviews for the pumps a priority, requiring that medical reviews be based on entire medical records and directing contractors to enhanced education about use and coverage of the pumps.

However, the OIG said CMS did not agree with the other recommendations because they could bring about delays in providing the pumps to patients.

To download a pdf of the report, click here.