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David McGill Blogger

Region A Posts New Spinal Orthoses Data

Posted by David McGill | May 04, 2015

​MAC Region A has published the latest results from its ongoing prepayment claim review of spinal orthosis claims (L0631 and L0637). While Region A breaks the reasons for denial down into numerous categories, here are what we think are the 3 most notable findings:

  • The claim denial rate was 83%;
  • 51% of suppliers who received requests for additional documentation failed to respond;
  • 14% of the claims lacked any proof of delivery.
How does this stack up to past review periods? The charts below show the trends.



What does this mean for you?

First, the exceptionally high claim denial rate means that Region A will continue its prepayment review of spinal orthoses claims involving L0631 and L0637.

Second, the failure of more than half the suppliers to respond to requests for additional documentation is the kind of red flag that leads the MACs and Medicare to worry that those underlying claims might be fraudulent. As a DMEPOS supplier, you're obligated to respond to requests for additional documentation. If you fail to do so, you may get referred to the National Supplier Clearinghouse, which has the authority​ to revoke your Medicare billing privileges.

Finally, even though the overall trend line is positive, the fact that we're still seeing double-digit denials for not having proof of delivery is a worrisome data point. Proof of delivery is one of the most basic and easy-to-satisfy supplier requirements. We would hope to see this number drop into the single digits after the next round of prepayment reviews.

We will keep you posted on new Region A results as they become available in the future.
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