Recent Medicare Audits Bring Mixed Results

Audit checklist on a deskThe results of recent Medicare audits of O&P claims bring a mixed message of relative success in some areas and continued deficiency in other areas. While improvements are always encouraging, the continued high error rates, specifically those involving claims for spinal orthoses indicate that there is still work to be done in understanding what Medicare expects and requires in order to reimburse O&P providers for legitimate services to Medicare beneficiaries.

The good news is found in recent audits results published by Jurisdiction B regarding its longstanding pre-payment review of high error rate DMEPOS claims. In the 4th quarter of 2014, Jurisdiction B reviewed a total of 5,893 claims of which 3,327 were denied, resulting in a claim error rate of 56.46%. While this error rate is still unacceptably high, it does continue the positive trend that has developed over the last year which began with a 68% claim error rate in the 1st quarter of 2014. Continued diligence by providers in making sure all of the documentation required for Medicare payment is contained in the patient’s medical record should drive the claim error rate increasingly lower with the hope that it is ultimately low enough to discontinue the pre-payment review.

The not so good news is the continued high claim error rates for spinal orthoses reported by both Jurisdiction B and Jurisdiction D. Jurisdiction B recently reported 4th quarter 2014 results that indicated a 95.80% error rate on spinal orthosis claims and Jurisdiction D reported a 4th quarter 2014 error rate of 99% for spinal orthosis claims. These high error rates clearly show that providers either do not understand the documentation requirements necessary for Medicare payment for these services or that the documentation requirements are so unreasonable that it is virtually impossible for providers to gather the necessary documentation to support the medical need for the spinal orthoses they are providing.

AOPA’s Take on this issue is mixed, just like the audit results. The continued downward trend of denials for high error rate services in Jurisdiction B is certainly encouraging but the error rates for spinal orthoses that are almost at 100% continues to be a source of frustration and confusion. We simply cannot be that bad when it comes to documentation for spinal orthoses.

AOPA encourages its members to review the LCD and Policy Article governing Medicare coverage of spinal orthoses and make sure that all of the documentation requirements are being met. especially the relatively new requirements that state that providers who bill for custom fitted orthoses instead of off the shelf orthoses document the specific modifications that were required to properly fit the orthosis to the patient.

AOPA will continue to monitor audit results published by the DME MACs and will continue to fight for the fair treatment of O&P providers.

AOPA’s Take. Where you go…..When you need to know!!!