High error rate for PMDs sticks

Friday, December 20, 2013

WASHINGTON – CGS, the Jurisdiction D DME MAC, released an overview of its K0823 prepay review activity this month, and the results are ugly.

From the second quarter of 2012 to the second quarter of 2013, the denial rate rose steadily until hitting a peak of 69%. The denial rate fell to 54% for the third quarter of 2013—not much better.

These rates transcend jurisdictions, stakeholders say, and are especially troubling considering all of the other pressures that HME providers face in today’s market. 

“No one can survive with that many denials,” says Peggy Walker, a billing specialist for The VGM Group’s U.S. Rehab.

The root of the problem remains lack of physician education, says Michael Blakey, president of DMEevalumate, which has developed a tool to help physicians complete the documentation process for PMDs.

“CMS is demanding accountability from practitioners and suppliers through documentation, but I think they’ve done a poor job educating the practitioners—putting providers in the position of main educational conduit to practitioners,” he said.

Blakey says when physicians only prescribe one PMD a month—or even one a year—there isn’t much of an incentive to learn the complicated documentation process. 

“It’s not a priority (for physicians), and providers only get one or two chances a year to let the doctor know they’re not compliant,” he said.

Still, Walker says providers must take responsibility for their own roles in the high error rate.

“I’m surprised at some of the things I’m looking at, like claims sent in without the detailed product description,” she said. “Since 2006, there’s been no such thing as a CMN for power mobility, and I’m still seeing those. Everyone’s mad at Medicare, but is anyone telling what the providers are sending in?”