Prepayment for CPAPS Fw: Prepayment Review Results - PAP Devices E0601
Jim DeWees
Description
Collection
Title:
Prepayment for CPAPS Fw: Prepayment Review Results - PAP Devices E0601
Creator:
Jim DeWees
Date:
2/14/2013
Text:
I thought I would share this with everyone, showing that it is NOT just O&P that Medicare is auditing and denying.
Thanks
Jim DeWees
From: Jurisdiction B DME MAC
Sent: Thursday, February 14, 2013 3:30 PM
To: <Email Address Redacted>
Subject: Prepayment Review Results - PAP Devices E0601
Select this link to view e-mail as a Web page, go here.
Prepayment Review Results - PAP Devices E0601
National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department has completed a prepayment target medical review of Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (OSA)/ HCPCS E0601. A selection of claims submitted from multiple suppliers were reviewed to assure that all coverage criteria and documentation requirements were met.
During the fourth quarter of 2012 (October 1-December 31, 2012), the DME MAC Medical Review Department processed sixty-one (61) claims that were developed for additional documentation. Two of these claims were reviewed as a reopening. Twenty- one (21) claims were allowed as billed and forty (40) claims were denied resulting in a claims error rate of 67.80%. The most common reasons for denial include:
a.. No face-to-face evaluation for OSA by the treating physician prior to thepolysomnogram
b.. No documentation of instruction on the proper care and use of the device
c.. ·No face to face evaluation by the treating physician showing use and benefit
d.. No or invalid proof of delivery
e.. Invalid detailed written order
f.. No documentation that beneficiary had a valid polysomnogram prior to enrollment
It is important for suppliers to understand and follow the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Enrollment Standards. The Jurisdiction B DME MAC Supplier Manual, Chapter 6 states the following:
A large number of suppliers fail to respond to requests for additional documentation. Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.
Suppliers should review the Local Coverage Determination (LCD) (L27230) for Positive Airway Pressure (PAP) Devices for the Treatment of obstructive Sleep Apnea and Policy Article (PA) (A47228). Suppliers should also become familiar with the Policy Education page on the National Government Services Web site and the Jurisdiction B DME MAC Supplier Manual for additional information relating to documentation, billing, and the review process. Suppliers are strongly encouraged to utilize the Web site resources in a effort towards quality improvement. Suppliers should also visit the Centers for Medicare & Medicaid Services (CMS) Web site for helpful information.
This email was sent to: <Email Address Redacted>
This email was sent by: National Government Services, Inc.
8115 Knue Rd Indianapolis, IN 46250 United States
CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or otherwise be protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Update Profile | One-Click Unsubscribe
Thanks
Jim DeWees
From: Jurisdiction B DME MAC
Sent: Thursday, February 14, 2013 3:30 PM
To: <Email Address Redacted>
Subject: Prepayment Review Results - PAP Devices E0601
Select this link to view e-mail as a Web page, go here.
Prepayment Review Results - PAP Devices E0601
National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department has completed a prepayment target medical review of Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (OSA)/ HCPCS E0601. A selection of claims submitted from multiple suppliers were reviewed to assure that all coverage criteria and documentation requirements were met.
During the fourth quarter of 2012 (October 1-December 31, 2012), the DME MAC Medical Review Department processed sixty-one (61) claims that were developed for additional documentation. Two of these claims were reviewed as a reopening. Twenty- one (21) claims were allowed as billed and forty (40) claims were denied resulting in a claims error rate of 67.80%. The most common reasons for denial include:
a.. No face-to-face evaluation for OSA by the treating physician prior to thepolysomnogram
b.. No documentation of instruction on the proper care and use of the device
c.. ·No face to face evaluation by the treating physician showing use and benefit
d.. No or invalid proof of delivery
e.. Invalid detailed written order
f.. No documentation that beneficiary had a valid polysomnogram prior to enrollment
It is important for suppliers to understand and follow the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Enrollment Standards. The Jurisdiction B DME MAC Supplier Manual, Chapter 6 states the following:
A large number of suppliers fail to respond to requests for additional documentation. Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.
Suppliers should review the Local Coverage Determination (LCD) (L27230) for Positive Airway Pressure (PAP) Devices for the Treatment of obstructive Sleep Apnea and Policy Article (PA) (A47228). Suppliers should also become familiar with the Policy Education page on the National Government Services Web site and the Jurisdiction B DME MAC Supplier Manual for additional information relating to documentation, billing, and the review process. Suppliers are strongly encouraged to utilize the Web site resources in a effort towards quality improvement. Suppliers should also visit the Centers for Medicare & Medicaid Services (CMS) Web site for helpful information.
This email was sent to: <Email Address Redacted>
This email was sent by: National Government Services, Inc.
8115 Knue Rd Indianapolis, IN 46250 United States
CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or otherwise be protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Update Profile | One-Click Unsubscribe
Citation
Jim DeWees, “Prepayment for CPAPS Fw: Prepayment Review Results - PAP Devices E0601,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/234726.
