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David McGill Blogger

New Prosthetic Prepayment Claim Review Results for MAC A

Posted by David McGill | May 05, 2015

​MAC Region A recently published the latest set of quarterly results for its prepayment claim review of K3 prosthetic claims. The review focused on 179 claims from 136 different suppliers. The key results:

  • The overall claim denial rate was 58%.
  • 23% of the claims lacked any medical record information;
  • 13% of the claims lacked sufficient physician corroboration;
  • 13% lacked a statement/reason for replacement in either the physician's prescription or the medical documentation; and 
  • 12% lacked proof of delivery.
How does this compare to previous results?

MAC A Claim Denial Rate.png

MAC A K3 Justification.png

What does this mean for you?

The good news is that in 4 of the last 7 quarters, the overall claim denial rate has been below 60%. And the percentage of claims that adequately justify the K3 functional level has consistently remained below the high water mark of 32% in March 2013 - or for 7 consecutive quarters. 

The bad news is that more than half of the reviewed claims fail to satisfy Medicare's requirements, and that has remained the case for 4 of the last 6 quarters. 
Based on these results, Region A announced that it will continue its widespread prepayment review of K3 claims. As always, make sure that you closely review the Local Coverage Determination for Lower Limb Prostheses to make sure that your claims comply with all applicable Medicare requirements. If you would like to verify whether your claims satisfy those criteria, we encourage you to use our strategic partner, The Audit Team, to perform its claim assurance review for your Medicare claims. You can reach out to The Audit Team directly at [email protected].
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