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David McGill Blogger

Number 10 From Region A

Posted by David McGill | July 31, 2014

​Last week DME MAC A released the 10th set of results since November 2011 for ​its ongoing prepayment claim review of K3 functional level prosthetic claims. The key highlights:

  • The overall claim denial rate was 60%;
  • 28.7% of the claims lacked physician corroboration;
  • 21.7% of the claims failed to justify the K3 functional level; and
  • 3.5% of the claims had missing proof of delivery. 
How does this rank historically? Of the 4 MACs, Region A has the longest and most consistent record of publishing its prepayment claim review results, so there's a nice data trail to look at:  
Claim Denial Rate.png 

No MD Corroboration.png 

Failed to Justify K3.png 
Missing PofD.png 
What does this mean for you?

First, based on these results, MAC Region A has announced that it will continue its prepayment claim review for K3 prosthetic claims.

Second, with the exception of the October 2013 results, the claim denial rate consistently has remained near or above 60%. Since there's now a long track record of K3 prosthetic claims in Region A failing more than half of the prepayment claim reviews, it's unlikely that the MAC will end them without both (a) a material reduction in the claim failure rate and (b) the lower claim failure rate occurring over an extended period of time. 

Third, the data show a generally consistent decline in the number of Region A K3 claims getting denied for lack of physician corroboration. For 5 out of the last 6 reporting periods,  only 30% or fewer of those claims have failed to meet the corroboration requirement, which is a positive trend.

Lastly, all of the bases for denial are both known and easily correctable. MAC Region A has consistently reported on the same data points for almost 3 years now. Stated another way, in issuing these reports, the MAC is giving you a general checklist of items that you need to make sure you have if you want to successfully overcome a prepayment claim review: (1) physician corroboration of the prosthetist's findings; (2) justification of the K3 functional level; (3) valid proof of delivery; and (4) though not specifically listed in this most recent report, prosthetist's notes detailing the appropriate functional level. (In past reporting periods, MAC A has reported that between 4% and 11% of reviewed claims contain no notes from the prosthetist mentioning the patient's functional level.) For more information about each of these items, make sure to review the Lower Limb Prosthetics Local Coverage Determination. 

If your company is still struggling with prepayment claim reviews, make sure to check out Ossur's strategic partner, The Audit Team. The Audit Team will ensure that your submissions are Medicare compliant for a fixed fee per claim. For more information, email The Audit Team at [email protected].

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