NHIC Continues Oxygen Prepay Review

HINGHAM, Mass. — On Friday, NHIC released its latest
quarterly findings in an ongoing widespread prepayment review of
oxygen claims (HCPCS E1390, E0431 and E0439) in DME MAC
Jurisdiction A.

Covering claims with service dates from January through March,
the complex medical review involved 297 claims submitted by 199
suppliers.

The results showed responses to the Additional Documentation
Request (ADR) were not received for 124, or 42 percent, of the
claims. For the remaining 173 claims, 70 claims were allowed and
103 were denied, resulting in a claim denial rate of 60
percent.

According to the DME MAC, the total denied allowance amount
(dollar amount of allowable charges for services determined to be
billed in error) divided by the total allowance amount of services
medically reviewed resulted in an overall Charge Denial Rate (CDR)
of 55.9 percent.

Based on the review, NHIC said the primary reason for denial was
missing documentation for treating physician visits:

• 42.7 percent of the denied claims were missing documentation
  for the treating physician visits (both 30 days prior to initial
  CMN and 90 days prior to recertification CMN);
• 24.3 percent of the denied claims were missing documentation
  for the treating physician visit (30 days prior to initial CMN);
  and
• 1.9 percent of the denied claims were missing documentation for
  the treating physician visit (90 days prior to recertification
  CMN).

NHIC’s previous findings covered the quarter from October
through December 2010 and resulted in a 71.5 percent CDR. While the
error rate has improved, the DME MAC said, the review will
continue.

For a full report on the review, which includes reasons for all
claim denials and examples of actual claims that were denied,
download a PDF from the NHIC website.