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David McGill Blogger

Region A Hits All Time Low ... And That's Good!

Posted by David McGill | October 27, 2014

Region A has published the results for its prepayment claim review of K3 claims. Here are the key data points:

  • The overall claim denial rate was 44%; that's the lowest denial rate since Region A began its prepayment claim reviews back in 2011;
  • 17.6% of the claims lacked physician corroboration, the second-lowest percentage since 2011;
  • 9.6% of the claims failed to justify the patient's functional level, also the second-lowest percentage for this category since 2011;
  • 4.2% of reviewed claims lacked proof of delivery; and
  • 13% of the suppliers sent additional documentation requests by Region A failed to respond.​

Both because of the level detail provided by Region A and the length of time it has been publishing these results we have the ability to see definite trends for several of these categories:

Region A Claim Denial Rate.png


Region A MD Corroboration.png


Region A Functional Level.png

What does this mean for me?

More than any other Region, the results from Region A provide an encouraging picture of supplier behavior. Denial rates have steadily fallen in many of the key measurement categories over the past 3 years. If the key trendlines continue to move in the same direction in future quarters as they have over the past 11, it's conceivable that Region A could elect to stop prepayment claim reviews of K3 prosthetic claims. How do you help that happen?

Continue to make sure that you comply with the requirements set forth in the Local Coverage Determination for lower limb prostheses and its accompanying Policy Article. And if your company still struggles with negative prepayment claim review results, we encourage you to contact Ossur's strategic partner, The Audit Team ([email protected]) and utilize their expertise to ensure compliance with prosthetic claims coverage requirements.

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