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David McGill Blogger

MAC Region A Results: Remember to Touch all the Bases!

Posted by David McGill | June 17, 2013

​MAC Region A has published updated results for its widespread prepayment claim review of functional level K3 prosthetic claims. The highlights:

  • The claim denial rate for Feburary-April 2013 was 69%.
  • The 69% number does not include the 21% of the time that prosthetists simply failed to respond to the MAC's requests for additional documentation.
  • 27% of the denied claims lacked clinical documentation to corroborate the physician's records and support medical necessity.
  • 8% of the claims lacked documentation from the prosthetist supporting the patient's functional level.
  • 31% of the claims had clinical records that failed to support the functional level of the item billed.
  • 15% of the claims lacked proof of delivery.

MAC Region A has announced that it will continue its widespread prepayment claim review of K3 claims based upon this data.

What does this mean for you?

First, if you want to limit the level of scrutiny on your claims by Medicare, you have to respond to their requests for information! Remarkably, more than 20% of prosthetists who receive requests for additional documentation from Medicare simply ignore them. If you do this, it will almost certainly trigger greater scrutiny by the ZPIC, an auditing entity that focuses more on fraud and abuse than the MACs.  

Second, 66% of the denied claims related to either lack of corroborating information from the physician or inadequate functional level documentation. Ossur R&R has downloadable resources addressing both of these issues in its Reimbursement Resources section. Use them.

Third, the 15% denial rate for claims lacking proof of delivery defies easy explanation. Documenting delivery of a prosthetic device is one of the most basic and fundamental Medicare requirements. Doing all of the work to jump through Medicare's various claim hoops only to fail on the delivery sheet is like hitting a home run in baseball and then forgetting to step on home plate.

Medicare wants you to touch all the bases. You must strengthen your internal controls today if you want to stay in business tomorrow! 

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