Sky-high denial rate for wound therapy pumps

Sunday, August 12, 2007

COLUMBIA, S.C. - The denial rate for negative pressure wound therapy pumps (E2402) in Jurisdiction A stood at 77.49% in the second quarter. That's not great, but it's better than the 94.04% denial rate in the first quarter, according to program safeguard contractor Tricenturion, which recently released the results of a pre-payment probe.

The review was triggered by a 2006 denial rate of 75.55% in a widespread probe of new products added to the group.

According to the second quarter review:
* 24% of claims were paid.
* 37% of claims were denied for non-response.
* 39% of claims were denied because medical information submitted did not demonstrate that coverage criteria was met.

The most common reasons for criteria not being met were:
* Initial criteria not met.
* No medical record information was submitted.
* No measurable wound healing from the previous month.

In July, the Office of Inspector General announced that a review of pump claims in 2004 found the CMS made $21 million in overpayments.