Are you Prepared for DME MAC Contractor Audits?

Durable Medical Equipment (DME) suppliers should be ready for MAC contractor audits this year. Medicare Administrative Contractors (MACs) are hired by the Centers for Medicare & Medicaid Services (CMS). MACs conduct post-payment claim reviews to protect the Medicare Trust Fund from processing incorrect payments.  

Currently, the Targeted Probe and Educate (TPE) Review Program is suspended, but once operative MACs will conduct these audits within TPE. Suppliers may be subjected to a MAC audit through random selection, unintentional billing errors, or other reasons determined by CMS.  

Targeted Probe and Educate (TPE) Review Program

The TPE program aims to improve the claims payment error rate while reducing the total number of appeals. Once in effect, the program will conduct claim reviews and educate suppliers on their claims submission.  

TPE Process

DME suppliers will have to complete up to three rounds of prepayment probes. Once MACs determine if sufficient claim review improvements are made, the review will end. Afterward, MACs will educate DME suppliers on how to improve their claims errors. 

If suppliers receive high error rates after all three rounds, MACs will refer suppliers to CMS for further action and review. 

Time Length for a TPE Review 

Typically, a MACs contractor audit will take at least one year to complete. For some companies, the review can last longer. 

TPE Review Expectations 

The MACs will review 20-40 claims per provider, per item or service per round. At the same time, they will focus on audits on specific providers instead of examining all providers of a particular service). 

HCPCS Codes for Post-Pay Service 

Below is a list of HCPCS descriptions and codes for the post-pay service.

  • Ankle-Foot Orthosis 
    • HCPCS Codes – L1902, L1906, L1971, L4396, L4397
  • Ostomy Suppliers 
    • HCPCS Codes – A4431, A4434, A5081, A5122
  • Urological Supplies 
    • HCPCS Codes – A4351, A4352, A4353, A4355, A4316
  • Knee Orthoses 
    • HCPCS Codes – L1833 and L1851
  • Surgical Dressing – Alginate 
    • HCPCS Codes – A6196 and A6212
  • Blood Glucose Test Strips 
    • HCPCS Codes – A4253
  • Lumbar Sacral Orthosis 
    • HCPCS Codes – L0650

To review specific HCPCS review announcements, click here.  

Need Help with Becoming Audit Ready?

Having a DME billing company help you become audit ready can save you significant time, money, and resources in the event of a MAC contractor audit. Medbill has a team of trained and skilled DME Billers who can help you become audit ready. 

Medbill has a 100% U.S.-based team that can offer audit assist services with personalized support. Contact Medbill today! 

Resources:

TPE Review Program

Post-Payment Reviews