DME MACS: High Denial Percentages Continue for Prepayment Reviews

The high denial percentages continue for Medicare prepayment reviews of standard power wheelchairs (DME MAC Jurisdiction A) and high-dollar items (DME MAC Jurisdiction B).

NHIC Corp., the Jurisdiction A DME MAC, reported a claims denial rate of 84 percent for its fourth-quarter widespread prepayment review of claims with HCPCS code K0823 — Group 2 standard power chairs with captain’s seating and patient weight capacities up to and including 300 lbs.

NHIC reviewed 382 claims submitted by 152 different suppliers from Oct. 1 through Dec. 31, 2012. NHIC said it didn’t receive additional documentation as requested for 26 percent of the claims.

NHIC also said 43 percent of the examined claims had problems related to the documentation requirement for face-to-face clinical evaluations. Among the examples of problems: “The evaluation did not provide a clear picture of the patient’s specific mobility limitations, i.e., upper- and lower-body strength, range of motion, coordination, pain levels, physical deformities and physical endurance.”

National Government Services’ (NGS) 2012 fourth-quarter prepayment review of “high-dollar” claims included claims for parenteral nutrition, prosthetics, speech-generating devices, and power mobility devices, among other types of products. The DME MAC reviewed 4,930 claims and denied 85 percent.

Among the most common reasons for denying the power mobility claims, NGS says, were missing seven-element orders, failure to prove medical necessity for the power mobility device as related to the specified medical condition, and failure to meet policy criteria for functions such as power tilt and recline.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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