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David McGill Blogger

When Scoring Less Than 50% is a Good Thing

Posted by David McGill | October 28, 2013

MAC Region A has posted new results from its widespread prepayme​nt review of K3 claims involving lower limb prosthetics. The key findings:


  • The MAC reviewed claims processed between May and August of this year.
  • Of the 151 claims reviewed, the MAC denied 70, resulting in a claim denial rate of 46%.
  • ​The charge denial rate was 35.3%, a 43% reduction in charge denial rate versus the February-April 2013 time period.
For the claims that failed to meet Medicare's criteria, we see the same group of suspects that we have written about repeatedly in the past:
  • 21% of the denied claims didn't have documentation justifying the functional level.
  • 14.5% of the denied claims lacked clinical corroboration of the prosthetist's records and therefore failed to demonstrate medical necessity.
  • 11% of the denied claims had no prosthetist evaluation/assessment documentation for the patient's functional level. And
  • 3% of the denied claims lacked a narrative description or manufacturer name and model number supporting proof of delivery.
What does this mean for you?

The good news is that the trend line is moving aggressively in the right direction in Region A. The sharp drop in both the claim denial rate and the claim charge rate suggests that Region A's prosthetists have shored up their documentation processes. If we continue to see these rates fall in future quarters, there may even come a day (gasp!) when Region A closes this widespread prepayment review.

The bad news is that based on these results, Region A announced that it will still continue its widespread prepayment review of K3 claims. So even though these results represent a significant improvement over older ones, the scrutiny will continue for the next few months.

How do you get the denial rate to drop further? Read and comply with the requirements of the Local Coverage Determination for Lower Limb Prosthetics! If you need a quick refresher on the key elements, review our 4-part series on the topic that began on August 14th of this year.


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