Every quarter my office downloads a print out from Palmetto GBA entitled
“Results of Service Specific Probe and Universal Reviews, 09/01/2004 to
12/31/2004, DMERC Region C, Medical Review Palmetto GBA.”The last
section contains information concerning orthotic claims, included under
this heading is also prosthetic claims but without a specific heading.
This analysis contains L codes, brief description of service, total
claims dollar amount, total dollar denied amount, GT (?) charges
(nonresponse), the number of suppliers and the number of claims.
Accepting the statistical information and dollar amounts to be
accurate—–I scratch my head and question the number of uncontested
denials.
For instance– L code L0478, TLSO flexion jacket. 100 % of the claims
were denied and there was 100% lack of follow up to the denials.
Consider this, L5649 Ischial containment ML socket. 52.2 % of the claims
were denied and of those denials 22.5% of the denials were not
contested.
Am I misinterpreting this information ? Our office fights tooth and nail
each time we get a denial. Why is not every O & P office challenging
these denials as Medicare statistics report? Is this true? These
uncontested denials represent a large dollar amount, and medicare saves
mega dollars denying these claims.
Gordon Bass CPO
