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David McGill Blogger

New OIG Report re. MAC Region C Claims

Posted by David McGill | July 21, 2013

The OIG published a new report on lower limb prosthetic claims last Friday. It focused on claims submitted in 2010-2011 from MAC Region C. The key findings? 

  • ​​​For the 2 years studied, OIG reviewed just over $6M in what it clasified as inappropriately-paid claims (average value per claim: just over $1,400.00).
  • 85% of those claims ($5.1M) had missing or incorrect documentation regarding the patient's functional level. More specifically, OIG cited instances of claims using L5930 (a K4-only code) being used for something other than a K4  patient.
  • 12% of those claims ($709,430) had unallowable quantities of socket inserts (i.e., more than 2 socket inserts per claim).
  • 3% ($183,527 had unallowable combinations of components (e.g., combining initial below the knee prosthesis code with unallowable code).
  • The OIG's review excluded claims undering RAC audit review.
What does this mean for you?

First, as Ossur R&R has stated repeatedly, review of lower limb prosthetics claims continues to focus on basic, simple requirements spelled out in the Lower Limb Prosthesis Local Coverage Determinations. Stated another way, nothing OIG said could reasonably be classified as new or surprising.

Second, OIG made two recommendations as a result of its report: (1) recover the approximately $6M in overpayments, and (2) monitor its processes more closely moving forward to prevent similar overpayments in the future. MAC Region C agreed with both of these suggestions.

As a result, prosthetic suppliers in Region C should expect to see continued scrutiny of their claims - particularly with respect to functional level documntation - moving forward, as well as recoupment demands for 2010-2011 claims. For a quick-hit K-level checklist that we've prepared for you, click here​.

Third, you should remember that these findings are for claims that are 2-3 years old. If you have already adjusted your practices based upon the August 2011 "Dear Physician letters" and closely adhere to the Local Coverage Determination requirements, you should continue to follow those processes and move forward confident that your approach satisfies Medicare's requirements.


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