COLUMBIA, S.C.--HME providers in Jurisdictions A and B have been slammed with claim denials in a number of areas this year, according to the results of several pre-payment reviews released by TriCenturion, the regions' DME PSC.

Most of the denials, according to the results, were due to inadequate, incomplete or improper documentation.

"Providers really need to pay attention to the guidelines that Medicare sets forth and abide by them," said Lisa Bargmann of Bargmann Management and Homecare Collection Service in Akron, Ohio. "Many providers are looking for easy answers to avoid the Medicare requirements; however, there are not any."

The reviews are part of a stepped-up effort by CMS to curtail reimbursement for unnecessary items and to combat fraud and abuse. Through its contractors, CMS has been scrutinizing claims for various products, a practice that is expected to continue and perhaps even escalate.

As a result of the intensified scrutiny, claim denials have soared, to as much as 93.6 percent for some power wheelchairs in Jurisdiction B and 99.25 percent for surgical dressings in Jurisdiction A.


"Denial rates have increased because there is a more concentrated effort on saving costs, especially when Medicare views that services are being provided that are not warranted under their guidelines," Bargmann said. "I expect those denials and audits to continue at a high amount."

Bargmann said providers can help guard against denials by making sure the patient qualifies for the equipment and having proof on file.

"Just because Medicare doesn't require you to send in the proof up front does not make it OK not to have the information," she said. "Each time a provider bills for a service that has not been qualified, that creates an opportunity for a take-back on not only that patient but an extrapolation across all patients. It also puts the provider number in jeopardy, along with additional fines and punishments."

Following are the results of TriCenturion's recent reviews:

--Power Wheelchairs HCPCS K0823.The Charge Denial Rate was 87.5 percent for Jurisdiction A and 93.6 percent for Jurisdiction B. This pre-payment review will continue.


--Negative Pressure Wound Therapy HCPCS E2402. This review was continued in Jurisdiction B as the result of an overall 83.72 percent CDR in a 2006 probe of new products added in the policy group. While results for the third quarter showed 25 percent of the claims were paid, 63 percent were denied because policy criteria were not met, and another 12 percent were denied for non-response. This pre-payment review will continue.

--Surgical Dressings HCPCS A6209-A6214. The CDR was 99.25 percent for Jurisdiction A and 98.77 percent for Jurisdiction B. This pre-payment review, which has been completed, showed that 71 percent of the claims were denied because medical necessity was not supported.

--Heat/Cold Application HCPCS E0215 (electric heat pad, moist) and E0217 (water-circulating heat pad with pump). The CDR was 84.38 percent for Jurisdiction A and 92.43 percent for Jurisdiction B. The review, which is complete, showed that in Jurisdiction A, 30 percent of the claims were denied as not medically necessary because the information submitted did not demonstrate that policy criteria were met. In Jurisdiction B, 59 percent of the claims were denied for the same reason.

--Rollabout Chair HCPCS E1035. This review, which has been completed, was conducted in Jurisdiction B. The CDR was 29.2 percent, with most claims being denied because they were deemed not medically necessary.