Medicare contractors 'nitpicking' claims

Friday, June 20, 2014

A recent bulletin stating that a prepay review of diabetes testing supplies resulted in a claim error rate of 99.2% doesn’t seem right, say providers.

“We haven’t seen anything like those error rates,” said Steve Nelson, president and CEO of Okeechobee Discount Drugs in Okeechobee, Fla.

National Government Services, the Jurisdiction B DME MAC, conducted a review of 8,758 claims submitted during the first quarter of 2014. The top reason for denial was lack of medical necessity; for those claims, missing progress notes were a key factor.

It’s a familiar frustration, say providers.

“How can I be responsible for another medical professional’s notes?” said John Keegan, pharmacist/owner of Terrace Heights Pharmacy in Hazelton, Pa. “I’d rather be mandated to just have the testing logs for everybody.”

When there are progress notes, they are being “nitpicked,” say providers.

“I do know the Medicare carriers have been nitpicking on progress notes from the physician, reflecting they have reviewed the testing results and test usage,” said Mark Libratore, president/CEO of Liberator Medical. “Many don’t have that in the charts, resulting in denials, but many of those denials are overturned at the ALJ level which we all know is broken.”

Provider Mark Gielniak says he’s getting paid on most of his claims, although he gets pushback on claims for patients not on insulin that test more than once per day.

“We have to challenge every one of those,” said Gielniak, vice president of Diabetes Plus in Warren, Mich. “They say the info submitted does not justify the need. I don’t know how much more you can justify it when you have the logs, the prescription and the doctors’ notes.”