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David McGill Blogger

MAC Region A Lower Limb Prosthesis Results

Posted by David McGill | April 28, 2016

NHIC, the DME MAC for Region A, released what is likely to be its last quarterly results for its prepayment claim review of K3 prosthetic claims. (Noridian will assume the contract for Region A in July.) Here are the key points:

  1. The overall claim denial rate was 49%.
  2. 7% of suppliers failed to respond to the MAC's request for additional documentation.
  3. 20% of the claims lacked information in the medical record supporting the patient's functional level.
  4. 6% of the claims failed to have adequate proof of delivery.
  5. 36% of the claims contained no reason for replacing the prosthesis in either the physician's order or in the medical documentation.

Here's how those results compare to preceding quarters:

Claim Denial Rate.png

 
No ADR Response.png

 
Failed to Justify K3.png

 
Missing Proof of Delivery.png

 
No Replacement Support.png

 

What does this mean for you?

Based on these results, Region A plans on continuing its prepayment claim reviews of K3 claims for lower limb prosthetics. Therefore, you should continue to scrutinize your claims closely before submitting them for payment to ensure that they meet all requirements, paying particular attention to the areas listed above.

In addition, as the charts in this post clearly show, while the MAC has tracked most of these issues since 2011, it started looking at one category - documentation supporting replacement of a prosthesis/component of a prosthesis - more recently (April, 2015). We have heard from customers that they are seeing increasing pushback from the DME MACs generally - not just in Region A - on this basis. Given the Region A trendline for this issue, which is moving the wrong way, we encourage you to verify that both your records and the physician's contain sufficient information justifying replacement of a prosthesis/part.

Lastly, whether Noridian will continue to publish these results after it assumes the Region A contract remains to be seen. NHIC has a long history of regularly reporting prepayment claim review results, allowing us to see how things have evolved over time. In Region D, Noridian has also tended to publish its results on a fairly consistent basis, but it has tended to focus its prepayment claim reviews more narrowly only on certain L codes, and not on K3 claims generally. 

We will keep you posted as events warrant moving forward.

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