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David McGill Blogger

Region D Publishes New TPE Results

Posted by David McGill | August 10, 2018

​Noridian, the DME MAC for Region D, has published the latest results from its Targeted Probe & Educate program for both spinal orthoses and AFOs/KAFOs for the April-June 2018 time period. Here's what you need to know:

  • The overall claim potential improper payment rate for spinal orthoses was 51% and for AFOs/KAFOs was 34%.
  • The top four reasons for denial were the same for both categories of orthoses: (1) no response to the Additional Documentation Response letter; (2) documentation failed to support coverage criteria; (3) claim was the same or similar to another claim already on file; and (4) documentation did not include verification that the equipment was lost, stolen, or irreparably damaged.

What does this mean for you?

The TPE program is designed to help suppliers understand Medicare's requirements. The good news here is that the TPE results show error rates significantly lower than historical prepayment claim review error rates, which generally exceeded 70% and often were higher than 90%. The bad news is that a significant percentage of claims filed by suppliers in the TPE program for the above-listed items still fail to satisfy basic requirements. 

As we have said repeatedly in the past, you must respond to an ADR letter. If you fail to do so, you may get referred to the National Supplier Clearinghouse for potential revocation of your Medicare billing privileges. Even if you know that you do not have the documentation requested in the ADR letter, reply to the DME MAC and acknowledge that fact.

You should also review the applicable Local Coverage Determination and review the coverage criteria to ensure that your claims satisfy those requirements. You are responsible for knowing what Medicare requires.

"Same or similar" denials are becoming increasingly frequent. Region D has two ways - the Noridian Medicare Portal and the Interactive Voice Response system - that you can verify whether a beneficiary has received a same or similar item within the applicable time period. Use these tools.

Finally, if you are claiming that an item was lost, stolen or irreparably damaged, you have to provide documentation establishing that fact. If you have a police report or insurance claim documentation, use it to help substantiate the claim.

We will keep you apprised of future TPE results as they become available. 

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