Ronda’s INSIGHT – O2 Widespread Prepayment Review – Two ways to reduce claim error rate

Posted on in Billing/Reimbursement

Oxygen Equipment - Fourth Quarter 2014 Widespread Prepayment Review Update Here are some results of recent prepayment audit for the portable gaseous system (E0431). It appears as if the claim error rate (denial) has increased to 90%. Why is the claim error rate increasing and can this error rate be reduced?


Claims Reviewed

Claims Error Rate

4Q2014 296 90.20%
3Q2014 217 77.90%
2Q2014 311 92.30%
The answer is YES! There are two ways to reduce the claim error rate. 1. Understand what Medicare expects and give it to them 2. If you don't have what Medicare expects do NOT provide the product as an assigned claim. Easier said than done you say? This may be true, but what choice do you have? To continue to accept denials and letting products just walk out the door for free? Really? Times have changed and the “good ol’ days” are gone. You have to start looking out for your company and learn to say NO. Let’s analyze the top denial reasons and see what we can learn from these mistakes and reduce the error rate. Data collected during the fourth quarter, identified the top denial reasons:
  • The detailed written order is required before delivery.
  • The ACA 6407 written order prior to delivery documentation did not clearly indicate the supplier’s date of receipt.
    • Insight – The HCPCS code E0431 falls under the ACA 6407 Face to Face (F2F) ruling that was implemented July 1, 2013. The rule states that for these HCPCS codes a detailed written order (DWO) is required prior to delivery. (Some know this as the WOPD). You, the suppler, may complete the entire DWO including NPI, then have the physician sign and date the order. The required elements for the DWO are the following: o Patient’s name o Narrative description of items being ordered o Date of order, and start date if different than order date o Liter flow o Frequency of use o Method of delivery o Ordering practitioner’s printed name o Ordering practitioner’s signature and signature date o Ordering practitioner’s NPI The DWO also requires a date received stamp that indicates the order was received prior to delivery of the portable system. I strongly suggest that it’s clear whom the date stamp belongs to by putting your company name with it. Just think if you were the auditor or reviewer looking at the DWO, ask yourself, is it complete and is it clear who this date stamp belongs to? Also note, that the CMN can act as the DWO making sure that it includes all the required elements and it’s received prior to delivery. When you receive the completed DWO, review the order looking for any missing information or mistakes so it can be corrected prior to delivery and/or prior to submitting the claim.
  • Document does not support beneficiary being mobile in the home.
    • Insight – When portable oxygen is ordered, the medical policy states the patient must be mobile in the home. Basically, this is to complete their ADLs. Remember that Medicare only pays for items to be used primarily within the home. While it’s ok for outside use, the main reason is for use within the home. This information needs to be documented in the medical record. Make sure to educate your referral sources so this information can be documented when they are assessing the medical need for home oxygen.
  • No evidence of blood gas results as reported on the CMN.
    • Insight – We all know that oxygen requires a CMN. The information that is completed on the CMN must have supporting documentation. For example, the blood gas result, which can either be an actual arterial blood gas (ABG) or the oximetry saturation testing, needs to be obtained for the referral. Make sure these same results match what has been completed on the CMN. The auditor/reviewer will look for the matching information that is completed on the CMN. It’s also important to note that the blood gas results cannot be written on the order. You must actually obtain the results, whether it’s the actual test results, or in the progress notes, nurse’s notes, respiratory therapy notes, etc. Make sure to get results and to make sure that it matches what has been completed on the CMN.
  • The qualifying blood gas study was not performed by a physician, qualified provider, or supplier of lab services.
    • Insight – In order for Medicare to consider payment for home oxygen, one the requirements is to have a blood gas study that must be performed by a provider qualified to bill Medicare such as a Part A provider, Laboratory, IDTF (independent diagnostic testing facility), or physician. Make sure the test results that you have received meet Medicare’s guidelines. You, the supplier, cannot have any part of the blood gas study.
  • One other insight, from my own review of oxygen claims from our members. When providing portable oxygen, make sure the blood gas results qualify the patient for portable oxygen.
    • Insight - At night test DOES NOT qualify a patient for portable oxygen. Only at rest or with exercise testing will qualify a patient for portable oxygen. For example, the patient has had the stationary oxygen unit for 10 months, their physician writes an order for portable oxygen. What do you do next? Make sure that the blood gas results you have on file were performed at rest or with exercise, NOT at during sleep. If the only results you have are during sleep, do not set the patient up with portable oxygen. New testing needs to be obtained first.
So YES the claim error rate can be significantly reduced by ensuring all requirements are met to the level Medicare expects and PRIOR to delivery. Remember it’s so much easier to implement and correct processes rather than making projects. Be proactive and not reactive! If you have any questions/comments regarding this article please contact Ronda Buhrmester at [email protected]