DME MAC launches ‘prepay probe’ with a twist

Friday, June 22, 2012

INDIANAPOLIS – It looks like another layer of prepayment reviews are on their way to home medical equipment providers.

National Government Services, the Jurisdiction B DME MAC, sent out a bulletin recently notifying providers of a “prepay probe,” which isn’t unusual, but this time, it will target “high dollar DMEPOS” in general.

“It’s not product specific, it’s dollar specific, which is a nuance that we don’t typically see them publicly announcing,” said Andrea Stark, a reimbursement consultant for MiraVista in Columbia, S.C.

While it’s not outside the scope of DME MACs to launch prepay reviews of high-dollar products, usually the contractors take their cue from the CERT program. When the program turns up a product with a high error rate, the DME MACs will often follow suit with a prepay review of that product.

National doesn’t give a threshold for what’s considered “high dollar,” but likely targets include power wheelchairs, negative pressure wound therapy, and orthotics and prosthetics, say industry consultants.

“What’s high dollar—is it $1,000?” said Sylvia Toscano, owner of Professional Medical Administrators in Boca Raton, Fla. “We’ll have to wait to find out, but it sounds like they’re going to pick things that are costly and notify us later of the particular codes.”

National’s success with this prepay probe may determine whether the reviews expand in scope and whether they expand to other jurisdictions.

“Any probe is a how-easy-is-it-to-shoot-fish-in-a-barrel scenario,” Stark said. “They are going to see what the error rates are to determine whether to keep down this road.”

National stated in the bulletin that providers of selected claims will be sent a letter in the mail requesting documentation to support the medical necessity for items billed, and providers must respond within a certain time frame. As with any prepay review, collecting documentation upfront is key, say consultants.

“It’s all about proactive documentation,” Toscano said. “Make sure that you’re expecting an audit for every file that you bill. This way, you have everything in your file that you need to respond and you don’t have to scramble for documentation under the gun.”


It doesn't matter if you have the right paper work or not. They will deny the claim and after several appeals, you may get paid in a year. By that time, you'll stop distributing that item for fear or an audit and you'll lose all your opportunity cost.

Noridian is not the Jurisdiction B DME MAC.  They are Jurisdiction D.  I think this article is meant to reference NGS.

This has been corrected in current version of story. Thanks!