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David McGill Blogger

Much Room For Improvement in Region D

Posted by David McGill | November 20, 2014

MAC Region D announced the latest prepayment claim review results for L5981 and L5987. 

They were not good.

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The bases for denial - not separately identified by L code - cover the same litany of issues identified in previous Region D prepayment claim review reports: inadequate proof of functional level; failure to respond to Additional Documentation Requests; documentation doesn't support need for replacement instead of repair; inadequate evidence that the patient will reach or maintain the claimed functional level within a reasonable period of time; failure to demonstrate that the patient is motivated to ambulate; and signature requirements not met. 

What does this mean for you?

Region D continues to have staggeringly high claim denial rates across the board for K3 feet. Based on this latest data, the MAC has announced it will continue its prepayment review of these claims.

The name of the game remains the same: get your basics right! A good starting point is our four-part series from August 2013 covering the lower limb prostheses Local Coverage Determination. If you don't know the LCD backwards and forwards and build your claims process around it, the results we're seeing in Region D will only continue. 

If you do that and are still getting poor results, or you just want to ensure that your claims meet Medicare's many coverage requirements, you need to contact Ossur's strategic partner, The Audit Team, which specializes in these issues. You can contact them at [email protected]

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