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David McGill Blogger

New Prosthetic Prepayment Results from Region A

Posted by David McGill | February 02, 2015

​DME MAC Region A released its latest prepayment claim review results for prosthetic claims last week. The review, which focuses exclusively on K3 claims, focused on 156 claims from 111 different suppliers. The key data points:

  • The overall claim denial rate was 43%;
  • 13% of the claims lacked any physician info;
  • 13% had insufficient corroborating info from the physician; 
  • 2.7% of the claims were missing proof of delivery; and
  • 11% of suppliers failed to respond to Medicare's Additional Documentation Requests.

How does this compare to previous prepayment claim review results?


No Corroboration.png

Missing POD.png

What does this mean for you?

While the overall claim denial rate continues to move in the right direction, falling to its lowest rate since MAC Region A started releasing results, the prepayment claim reviews for K3 claims will continue. That being said, we find the overall trendlines for the key measure encouraging.

If Region A's O&P's can continue to push these numbers in the direction they've been going in for the last 4 quarters, the DME MAC could elect to stop the prepayment claim review of K3 claims in the future. The key to getting to that point? As always, go back to basics: (1) review the Local Coverage Determination for Lower Limb Prostheses; (2) make sure to adequately document the patient's functional level; and (3) work closely with the relevant physician to ensure that her records similarly corroborate your functional status findings.

If you want to go the extra step to make sure that your claims are Medicare compliant, you can also work with Ossur's strategic partner, The Audit Team, to assist you. You can reach 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]