Widespread Pre-Payment Reviews in Regions B and C

What You Need to Know

CGS, the DME MAC for Regions B and C, has announced a prepayment medical record review program targeting claims submitted by new suppliers across six high-risk product categories. The prepayment reviews include lower limb orthoses, upper limb orthoses, and spinal orthoses. 

CGS will initiate these reviews by issuing Additional Documentation Requests (ADRs) seeking the following information:

• The treating practitioner's written order;
• Medical records establishing medical necessity;
• Any other relevant documentation;
• Proof of delivery; and
• An Advance Beneficiary Notice if the supplier issued one.

What This Means for You

First, CGS does not specifically define "new supplier" in its announcement. It is possible that any supplier that has not yet had to go through Medicare reaccreditation at least once could be included in this category.

Second, if you are a new supplier billing lower limb orthoses, upper limb orthoses, or spinal orthoses, you will likely receive ADR letters in the coming weeks and months. You must respond promptly to ADRs. Failure to respond will result in denial of the claim at issue and can lead to referrals for more invasive audits or investigations. 

Lastly, we recommend that all suppliers use this as an opportunity to review your documentation protocols. Ensure that for every claim submitted involving these devices, you retain complete medical records, signed orders, proof of delivery, and any applicable ABNs. Your best defense against denials and regulatory referrals under this new review initiative is consistent and strong documentation practices.

 To read the complete CGS announcement, including the other product categories included in the prepayment review process for new suppliers, click here.