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David McGill Blogger

Region B Posts Spinal Orthoses Prepayment Review Results

Posted by David McGill | December 16, 2015

The DME MAC for Region B released its prepayment claim review results for claims reviewed between July 1 and September 30, 2015 for codes L0450-L0640. The claim denial rate dropped significantly versus the previous two quarters, but still leaves considerable room for improvement:

  • The prepayment review resulted in the denial of 229 out of 289 claims reviewed (79% claim error rate);
  • 62 of the denials resulted from the supplier's failure to provide any documentation to the MAC in response to its additional documentation request (22%).

Region B listed the following as the top substantive reasons for denial:

  • Failure to satisfy the LCD's coverage criteria;
  • No proof of delivery;
  • No medical records provided;
  • Detailed written order didn't include a detailed description of the item;
  • No detailed written order.

What does this mean for you?

We think there are 3 items of note resulting from this data.

First, as noted above, the results are a decided improvement over the previous two quarters:

Region B Orthosis Denial Rate.png

Whether this is a one-time aberration or a broader trend remains to be seen, but the new information is positive. At the same time, however, there's clearly room for continued improvement.

Second, the 22% "no response to ADR's" data point is troubling. The MACs tend to view a non-response as suggestive of potentially inappropriate supplier billing. So as we've said countless times before in these e-pages, if you receive an ADR, respond - even if you do not have the information that is being requested! Failing to answer these information requests can lead to investigation and/or suspension of your Medicare billing privileges.

Third, based on these results, Region B has announced that it will continue to audit these spinal orthoses codes. So make sure to review the LCD for spinal orthoses, integrate all of its requirements into your claim process, and ensure that you've satisfied all of them for every spinal orthosis claim before submitting it for payment.

We will keep you updated regarding future prepayment review results from all DME MAC regions as they become available.

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