Wiki DME Question -Medicare as primary insurance

[samorehouse]

We have a patient that has Medicare as primary insurance. Claim was submitted to Medicare for several "L" codes, and a handful of the items paid, and others were denied as not medically necessary. As a result, we had to file an appeal as the provider felt that not only were these items necessary, but without them, patient would not be able to ambulate! We were able to provide Medicare with all of the information required for the appeal, however the appeal was denied because the PCP failed to provide an adequate chart note. This is the first time that I have had to file an appeal, much less have it deny. Does anyone have any experience with this type of denial, and if so, what would be our recourse at this time? This provider is out $ 3500.00 based on an inadequate chart note, and although that note was only part of the appeal, it appears as though the remainder of the information provided, was overlooked. Any suggestions would be greatly appreciated. Thanks, Sharon

 

[jlynnhowe]

I was actually working in DME up until this past March. I haven't dealt directly with denials, more in intake and documentation review, but I have heard a number of DME billing 'horror stories' from within the company I worked for, including a claim that was denied just because the patient's address was incorrect on the claim form.

My take on the situation, and that of many DME providers in the industry, is that after widespread fraud and waste involving DME, Medicare is focusing heavily on this area for audits and denials. Probably too heavily, or at least too heavy-handedly.

My experience is that if the physician's note for the patient doesn't state directly-almost verbatim-that they meet the requirements of the Medicare LCDs for the equipment, there may be trouble. What type of equipment was involved here?

 

[samorehouse]

Hello, The claim was inclusive of the following codes: L5301, L5620, L5637, L5940, L5910, L5987, L5986, L5629, L5679, L5647, L5685, L8400, L8420, and L8470. Of the entire claim, L8420 and L8470 paid and the remainder denied, requesting documentation of medical necessity. I have to say that this provider is absolutely excellent about documenting his portion. However, they denied the medical necessity based on the PCP documentation. The exact wording from Medicare: " Our medical staff reviewed the documentation submitted, and is missing documentation from the beneficiary's medical record prior to the date of service, documenting a reason for the replacement of the prosthesis and components. In the note dated 10/24/14, there was no mention for the need for replacement. An addendum was added on 3/26/15, which was months after delivery and after the original denial. The information in the addendum appears to contain new medical documentation that was not noted on the original progress note. There was no statement for replacement on the written order, therefore the items cannot be allowed." However, they did pay for two line items. This was denied in the form of a first appeal. I just don't have enough experience to know what would be the next step in this process. Thank you.

 

[Michelle_Eskelsen]

Morning

I work at a DME facility and while we do not manage orthoses or prosthetics I am familiar with the appeals process with Medicare. Due to prior abuse they have stepped up their ADRs to substantiate needs. First order is to do the redetermination on a denial. When I send those, I always send it in the order I think it should be reviewed, i.e. WOPD, documentation, sales order, equipment checklist, CMN, EOB(if applicable). Also I have a cover sheet between each item with the heading of what is next. On the encounter forms they do allow you to put a star or arrow pointing to the proof of medical necessity or date etc. Also, remember the Timeline is very specific for Medicare, things have to be in a dated order... If this doesn't work, reconsiderations are next. I have successfully appealed 90% of my denials due to attention to detail, and definitely if I have issues with doctor notes, I speak with their nurses or send Dear Physician letters. Most providers understand the Medicare specificities and will accommodate as needed, at least most I deal with.
I know this may not answer your question specifically, but I also recommend reading on your jurisdictions website and LCD, they are extremely helpful. I also recommend calling your jurisdiction, the customer care team are super great at that too!!
Michelle