Tag: Prepay review

NASHVILLE, Tenn. -The Jurisdiction C DME MAC has announced widespread prepayment reviews for power tilt (E1002) and power tilt and recline (E1007) wheelchairs. If their claims are selected for review, providers will receive a request for additional documentation that must be received within 45 days, or the claims will be denied.

A claim review of the initial month of therapy for CPAP devices (E0601) for Oct. 1, 2013, to Dec. 31, 2013, showed a denial rate of 48%. In the previous quarter, the rate was 56%. The most common reason for denial: The documentation did not include a copy of a board certified document, screen print from a national certification agency, etc., that verifies that the physician who interpreted the sleep test met policy requirements (30%)�A claim review for oxygen concentrators (E1390) for Oct. 1, 2013,...

INDIANAPOLIS - The claim error rate for Group 2 pressure reducing support surfaces (E0277) was 74% between July 1, 2013, and Sept. 31, 2013, according to a prepay review by National Government Services (NGS), the DME MAC for Jurisdiction B. NGS reviewed 275 claims: 239 were denied and 36 were approved. It found that 21% of claims were denied due to no response to the additional documentation request letter�The claim error rate for glucose test strips (A4253) was 98.5% between Oct. 1, 2013, and Dec....

INDIANAPOLIS - National Government Services (NGS), the DME MAC for Jurisdiction B, has reported a claims error rate for power wheelchair bases with options and accessories of 64% between April 1, 2013, and June 30, 2013. NGS examined 754 claims that were developed for additional documentation and it paid in full only 234 claims. The most common reason for denials: The physical and functional findings that were documented in the medical records failed to clearly establish medical necessity for power...

Most of the guidelines for prepayment medical review are found in manual guidance issued by CMS. However, the agency did issue a regulation in 2008 requiring contractors to terminate the prepayment medical review of a provider no later than one year following the initiation of the review or when calculation of the error rate indicates the provider reduced its initial error rate by 70% or more. The regulation further required contractors to conduct, at a minimum, quarterly evaluations.  On Nov....

BALTIMORE - CMS issued a proposed rule this week that details its plans to require a face-to-face evaluation within 90 days of a written order for certain high-cost durable medical equipment.The rule gives four criteria that would subject items to the requirement:1.)    items that currently require a written order prior to delivery;2.)    items that cost more than $1,000;3.)    items that we, based on our experience and recommendations from the DME MACs,...