CIGNA Will Require Pre-pay Review for O2 Claims
Official release from DME MAC cites high rate of errors in claims as reason for requirement.
- By David Kopf
- Jun 17, 2010
In an official notice, CIGNA Government Services, the Jurisdiction C DME MAC, said it will implement a service-specific Medical Review edit for oxygen concentrators (HCPCS code E1390) that will require pre-pay review for the devices.
CIGNA said the edit resulted from data that demonstrated “a high claims payment error rate for this product category.”
Claims subjected to this edit will be developed for additional documentation. CIGNA said in its release that providers receiving a development letter should follow its instructions to supply the specific documentation requested. Suppliers will be asked to submit documentation including, but not limited to:
- Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order).
- Detailed written order.
- Delivery documentation.
- Initial CMN plus any required recertification and/or revised CMNs.
- Medical records showing initial qualifying arterial blood gas or oximetry test.
- Relevant medical records verifying that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy and that alternative treatment measures have been tried or considered and deemed clinically ineffective.
- Contemporaneous (within six months of date of service on claim) medical records confirming that the beneficiary continues to use oxygen in the home.
Additional records needed for beneficiaries qualifying under group II criteria would include:
- Medical records verifying that the patient has dependent edema suggesting congestive heart failure, or pulmonary hypertension or cor pulmonale, or erythocythemia with a hematocrit greater than 56 percent.
- Medical records showing recertification qualifying arterial blood gas or oximetry test (if claim is for a date of service four or more months after initial date of service).
Additional records needed for beneficiaries qualifying with a home sleep oximetry:
- Treating physician's order requesting an overnight pulse oximetry test written before the test was performed.
- Documentation that the test was performed under the direction and/or instruction of a Medicare-approved Independent Diagnostic Testing Facility (IDTF). This documentation should include the name/address of the IDTF.
- Information identifying the type of test unit used for the testing.
“This is outrageous and a reflection of what CMS is doing to harm legitimate providers statewide and nationwide,” read a statement from the Florida Alliance of Home Care Services. “As the Florida State Association we need to find out exactly why CIGNA has decided upon this course of action rather than utilizing the educational process, ZPIC, RAC and CERT audit procedures. Why the sudden escalation of one product without seeking alternative measures as indicated in the provider manual?”
David Kopf is the Editor of HME Business.