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David McGill Blogger

MAC Region A Q1 Prosthetic Review Results (With Charts!)

Posted by David McGill | April 25, 2014

MAC Region A has published the latest prepayment claim review results for the K3 claims it has reviewed. Here are the key points:

  • 11% of suppliers failed to respond at all to the Additional Documentation Request.
  • Excluding the suppliers who didn't respond to the ADR, the claim denial rate was 77%. For those claims
    • 57% lacked corroborating information from the physician;
    • 22% failed to justify the K3 functional level;
    • 7% lacked any documentation - any - from the prosthetist; and
    • 1% lacked proof of delivery.

What does this mean for you?

First, based upon these results, MAC Region A will continue its widespread prepayment review of K3 claims. 

Second - and not to sound like a broken record - we continue to see the same kind of results over and over in Region A. However, viewing a few of these data points in visual form - MAC A has released 9 reports since announcing the prepayment claim review in August 2011 - shows some interesting trends.

Chart 1: MAC Region A Claim Denial Rate

MAC A Claim Denial Rate.png 

The overall claim denial rates appeared to be on a generally downward trend. However, the last 2 reports in Region A have seen the claim denial rate creep back up from a low of the mid-40% range back up to nearly 80%. This suggests that most of the suppliers reviewed over the last two quarters have failed to optimize their claims processes effectively.

Chart 2: MAC Region A Failure to Respond to ADR

MAC A ADR Non-Respond.png 

The overall rate of suppliers failing to respond to ADRs is relatively low. However, one would hope that these numbers would consistently be in the single digit range. That has only happened in 3 of the 9 quarters reviewed.

Chart 3: MAC Region A Claims Without Corroborating MD Info

MAC A MD Corroboration.png 
 
By far the most positive trendline overall, the data shows that suppliers in Region A have gotten significantly better since August 2011 at getting corroborating information from their physicians. However, the uptick in claims without corroborating information the last 2 quarters bears close watch in future MAC Region A reports.

Conclusion

​Keep it simple: (1) respond to ADR requests; (2) get corroborating physician information; and (3) exhaustively document your patient's functional level. For tips and downloadable resources, make sure to visit our Reimbursement Resources link on the Ossur R&R page. Equally important, for services that will provide you "hands on" help with these (and other) issues, visit the all new Quality Assurance Review and O&P Billing Practices links on the Ossur R&R Page.

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