Prepayment review produces 81 percent claims error rate

National Government Services, Jurisdiction B Medical Review Department is reporting an 81 percent claims error rate in a prepayment medical review process being conducted for K0823 power chairs.

The Jurisdiction B DME MAC reviewed claims submitted by multiple suppliers, and between Oct. 1, 2011, and Dec. 31, 2011, examined 615 claims. Of these, 119 claims were partially or fully paid. The remaining 496 claims were denied, resulting in an 81 percent claims error rate, the DME MAC reported last week.

The most common reasons for the power wheelchair base (K0823) denials were:

• No valid medical records were found in the supplier’s response, or the medical records received did not establish medical necessity (55 percent)
• There was not sufficient evidence that a physician face-to-face mobility examination occurred
• The required seven element order or detailed product description was invalid or incomplete
• There was no response to the Medical Review additional documentation  request

Some HME industry advocates have been sharply critical of CMS for creating an overcomplicated claims submission system that routinely produces claims error rates greater than 75 percent.