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David McGill Blogger

Region A Says Prepay Prosthetic Reviews Here to Stay (For Now)

Posted by David McGill | March 11, 2013

​Last Friday, MAC Region A published the latest results for its ongoing widespread prepayment complex review of lower limb prosthetic claims.

Key findings:

  • The focus of this review, like previous ones, was on claims involving the K3 functional level;
  • Prosthetists failed to respond to 13% of the claims reviewed when asked for additional information.
  • For the remaining claims, the claim denial rate was 77% (i.e., MAC Region A determined that 77% of the claims failed to meet Medicare's payment standards).
  • Of the denied claims, Region A rejected 32% for failing to adequately justify the K3 functional level, 30% for lacking physician corroboration of prosthetists' records, 12% for missing proof of delivery, and 4% for missing the prosthetist's assessment of the patient's functional level.

What does this mean for you?

First, MAC Region A concluded that based upon these results, it will continue its widespread review of lower limb prosthetic claims involving the K3 functional level moving forward. This means that prosthetic suppliers in Region A should expect ongoing scrutiny of these kinds of claims.

Second, we find it interesting that the MAC differentiated between the 4% of claims denied for "missing the evaluation/assessment documentation for the functional level of item(s) billed (prosthetist assessment) on the one hand, and the 32% of claims denied because the "clinical records [ ] did not justify the functional level of the billed item. While the distinction between these two categories isn't entirely clear, our current interpretation of the data is that 96% of prosthetists did include evaluation/assessment documentation regarding functional level, demonstrating that prosthetists are, the vast majority of the time, fulfilling their responsibilities. On the other hand, we believe the 32% failure rate for "clinical records" may be referring to physician documentation.

Third, you have to know Medicare's requirements backwards and forwards, and there are no shortcuts here. However, we have made key resources available to you right within the web pages of Össur R&R. Specifically, in the Reimbursement Resources link we have the following documents that will help you make sure you dot your i's and cross your t's when preparing claims for submission to Medicare: (1) Lower Limb Prosthesis Documentation Checklist 2013, and (2) Physician Worksheet for Prosthetic Documentation 2013. We encourage you to click through to those resources and integrate them into your standard operating procedure to help avoid the kinds of results discussed in the latest report from MAC Region A.

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