National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review department continues to conduct a prepayment medical review of high error audit claims. For the first quarter of 2013, submitted claims from multiple suppliers were reviewed to assure that all coverage criteria and documentation requirements were met.
Regarding O&P, the claim error rate decreased from a 100 percent error rate in July 2012 to a 46 percent error rate by the end of the first quarter of 2013. The most common reasons for denials are listed below:
- Proof of delivery was either missing or missing critical elements including the date, a beneficiary signature, or a list of items received.
- Returned medical documentation does not meet Local Coverage Determination (LCD) criteria for replacements: (1) a change in the physiological condition of the patient, (2) irreparable wear of the device or a part of the device, and (3) 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 replacement cost of device or of the part being replaced.
- Medical records either were not received, not signed, or failed to provide documentation to support the functional class.