National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has announced that it will continue to conduct a prepayment medical review of high-dollar claims, including those for prosthetics.
For the fourth quarter of 2012, 4,930 high-dollar claims based on a targeted service(s) from suppliers of parenteral nutrition, prosthetics, orthotics, power mobility devices, speech generating devices, external infusion pumps, ventilators, negative pressure wound therapy pumps, surgical dressings, and oral-anticancer drugs were reviewed for medical necessity. Of those claims, 4,197 were denied, resulting in an 85 percent claims error rate.
The most common reasons for denial of prosthetics claims were:
- Proof of delivery not submitted. Proof of delivery submitted were missing critical elements including date, beneficiary signature, or list of items received.
- Medical documentation provided insufficient to support medical policy criteria for replacements:
- A change in the physiological condition of the beneficiary; or
- Irreparable wear of the device or a part of the device; or
- The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or of the part being replaced.
- Invalid signatures were found on medical records.
NGS has provided the following links to educational material so suppliers can be in compliance with documentation requirements:
- The local coverage determinations (LCDs) and related policy articles for items that are billed by suppliers can be found under Medical Policy Center (LCDs).
- Policy Education provides additional information for medical policies.
- Chapter 8 of the Jurisdiction B DME MAC Supplier Manual documentation requirements.
NGS reminded suppliers that failure to respond to requests for additional documentation is in violation of supplier standard 28, which states that: “Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.”
