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David McGill Blogger

Getting Better in B?

Posted by David McGill | June 03, 2013

MAC Region B has posted new results for its prepayment review of "high error audits." Prosthetics and orthotics have both fallen into this "high error audit" category historically, with a claim error rate of 100% in July 2012. (Meaning that based on MAC Region B's criteria, every prosthetic and orthotic claim it reviewed at that time failed to meet Medicare claim criteria.)

But for a change, we see a bit of good news from Region B. Based on the Q1 2013 data, the claim error rate for O&P claims has dropped to 46%. 

While this shows significant improvement year over year, it also means that close to half of all O&P claims still fail to meet basic Medicare coverage requirements. According to MAC Region B, the most common reasons for denial for O&P claims remain:

  • missing proof of delivery or incomplete proof of delivery (e.g., missing signature, date, list of items received);
  • failing to comply with the applicable Local Coverage Determination
    • No records showing medical necessity due to a change in the patient's physiological condition;
    • No documentation showing irreparable wear of the device or a part of the device; and
    • No evidence that the device being replaced requires repairs and that the cost of such repairs would be more than 60% of the cost of a replacement;
  • missing medical records, unsigned medical records, or medical records lacking functional level documentation.
Remember that Össur R&R contains numerous resources to help you confirm that you've satisfied all of the above-referenced requirements. Remember to click on the Reimbursement Resources​ link in R&R to access those tools, including numerous checklists for prosthetic and orthotic claims.

Also remember that Össur has partnered with HMG/The Audit Team to offer a first-of-its kind Quality Assurance Review package for claims involving Össur's Bionic Products. For more information about this program, please call 888-833-3478. 
Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]