URGENT Region C DMERC Update
NAAOP
Description
Collection
Title:
URGENT Region C DMERC Update
Creator:
NAAOP
Date:
3/12/2002
Text:
REGION C DMERC HALTS PROBE AUDITS OF O&P PROVIDERS: MAY PLACE SOME
PROVIDERS ON MEDICAL REVIEW
In recent weeks, the Region C DMERC, Palmetto GBA, has delayed payment
on some Medicare O&P claims until additional information justifying
medical necessity has been submitted by orthotists and prosthetists who
provided the O&P services. This additional information has been
required due to an 'increased amount of utilization' of certain items of
O&P. These documentation requests have created administrative burdens
and long delays in the payment of Medicare claims submitted by O&P
providers.
Several NAAOP members and friends brought this issue to our attention
and we have contacted the Region C DMERC to discuss this important
issue. Charlene Craven, Region C DMERC Director of Medical Review,
along with the Region C Medical Director, Dr. Paul Metzger, have assured
us that they have halted these pre-payment 'probe audits' as of the week
ending March 8, 2002.
Region C identified approximately seven HCPCS Level II codes that it
believed might have been the subject of inappropriate payment due to
increased utilization. The carrier took a random sample of 250 claims
from each code through a system 'edit,' and is now in the process of
analyzing claims data relating to these codes, on a supplier by supplier
basis, to determine whether there is a high denial rate.
If the outcome of this analysis reveals a high denial rate, the supplier
will be educated as to the propriety of submitting appropriate claims
using the seven codes in question. Such providers will also be placed
on medical review and will likely continue being subjected to the
probe audits. If there is not a high denial rate, then the outstanding
claims will be paid, the edit will remain turned off, and
practitioners should experience typical claims process procedures.
NAAOP is continuing to pursue this issue in an attempt to work with
DMERC Region C to find alternatives that will permit the DMERC to
fulfill its role in maintaining the integrity of the Medicare program,
while decreasing administrative and financial burdens on O&P
practitioners. NAAOP should be notified immediately if an O&P
practitioner experiences one of these pre-payment audits. Thank you for
your cooperation.
Prepared by Peter W. Thomas, NAAOP General Counsel
and Justin Hunter, Esq., Powers Pyles Sutter & Verville, P.C.
March 12, 2002
Visit our web site at www.oandp.com/naaop
Come share YOUR view! Government Relations is what WE do!
PROVIDERS ON MEDICAL REVIEW
In recent weeks, the Region C DMERC, Palmetto GBA, has delayed payment
on some Medicare O&P claims until additional information justifying
medical necessity has been submitted by orthotists and prosthetists who
provided the O&P services. This additional information has been
required due to an 'increased amount of utilization' of certain items of
O&P. These documentation requests have created administrative burdens
and long delays in the payment of Medicare claims submitted by O&P
providers.
Several NAAOP members and friends brought this issue to our attention
and we have contacted the Region C DMERC to discuss this important
issue. Charlene Craven, Region C DMERC Director of Medical Review,
along with the Region C Medical Director, Dr. Paul Metzger, have assured
us that they have halted these pre-payment 'probe audits' as of the week
ending March 8, 2002.
Region C identified approximately seven HCPCS Level II codes that it
believed might have been the subject of inappropriate payment due to
increased utilization. The carrier took a random sample of 250 claims
from each code through a system 'edit,' and is now in the process of
analyzing claims data relating to these codes, on a supplier by supplier
basis, to determine whether there is a high denial rate.
If the outcome of this analysis reveals a high denial rate, the supplier
will be educated as to the propriety of submitting appropriate claims
using the seven codes in question. Such providers will also be placed
on medical review and will likely continue being subjected to the
probe audits. If there is not a high denial rate, then the outstanding
claims will be paid, the edit will remain turned off, and
practitioners should experience typical claims process procedures.
NAAOP is continuing to pursue this issue in an attempt to work with
DMERC Region C to find alternatives that will permit the DMERC to
fulfill its role in maintaining the integrity of the Medicare program,
while decreasing administrative and financial burdens on O&P
practitioners. NAAOP should be notified immediately if an O&P
practitioner experiences one of these pre-payment audits. Thank you for
your cooperation.
Prepared by Peter W. Thomas, NAAOP General Counsel
and Justin Hunter, Esq., Powers Pyles Sutter & Verville, P.C.
March 12, 2002
Visit our web site at www.oandp.com/naaop
Come share YOUR view! Government Relations is what WE do!
Citation
NAAOP, “URGENT Region C DMERC Update,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 25, 2024, https://library.drfop.org/items/show/218696.
