Category: Audits

The value of prescreen review prior to a Medicare Request for Prior Authorization

By Kim Turner, RN, Clinical Consultant and Lisa Eick, RN, Clinical Consultant If you provide complex rehabilitative equipment to Medicare beneficiaries, you are likely familiar with the Medicare Prior Authorization Requests program for the K0856 (Group 3 standard, single power option) and the K0861 (Group 3 standard multiple power option) wheelchairs. The program began for

Read the full article »

OIG Announces reviews on OTS orthotic devices

As part of the Office of the Inspector General’s (OIG) ongoing work plan efforts, off-the-shelf (OTS) orthotic devices were added to the active work plan items list last week. The OIG announced that, since 2014, claims for three OTS orthotic devices (L0648, L0650, and L1833) have grown by 97 percent and allowed charges have grown by

Read the full article »

RAC AUDIT ALERT: VENTILATORS SUBJECT TO DWO REQUIREMENTS

On January 11, 2018, Performant Recovery, the National DMEPOS RAC, added ventilators to their approved issues list. According to their website, Performant Recovery will perform complex reviews on ventilator claims subject to DWO requirements on or after January 1, 2016 to determine if coverage criteria and/or medical necessity requirements were met. Codes included in the audit:

Read the full article »

RAC AUDIT ALERT: Respiratory Assist Devices

On December 17, 2017, Performant Recovery, the National DMEPOS RAC, added Respiratory Assist Devices (RADs) to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if coverage criteria and/or medical necessity requirements were met. Codes included in the audit are: E0470, E0471 Performant will review

Read the full article »

UPDATE: Targeted Probe and Educate (TPE) Pilot

UPDATED: October 6, 2017 In October 2017, the TPE Pilot is now open to all four DME MAC Jurisdictions. Suppliers will be chosen based on the following criteria: Items that pose the greatest financial risk to the Medicare Trust Fund – HCPCS with high national error rates, high dollar equipment, etc. Individual suppliers with high

Read the full article »

Audit Alert: AFO & KAFO Orthoses

On July 5, 2017, Performant Recovery, the National DMEPOS RAC, added AFO and KAFO orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if basic coverage criteria outlined in the Local Coverage Determination (LCD) for AFO/KAFO Orthoses was met. Performant will review medical

Read the full article »

Improvements to the Adjudication Process of Serial Claims

A major win for DME Suppliers was announced yesterday, as CMS released information regarding improvements to the adjudication process of serial claims. Effective April 7, 2017, CMS has implemented changes to improve the processing and adjudication of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items. Prior to April 2017,

Read the full article »

Audit Alerts

DME contractors perform pre- and post-payment reviews on a continual basis. Through data analysis, the medical review department determines the codes they will review and then sends Additional Documentation Request (ADR) letters to suppliers that bill those codes. The following list includes those codes currently being reviewed amongst all four DME jurisdictions. Positive Airway Pressure

Read the full article »