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.