Speaker: 90% of Medicare payment denials are preventable

Lesleigh Sisson

ATLANTIC CITY, NJ — Although approximately 90% of Medicare payment denials are preventable, only two out of three of denials are recoverable, according to Lesleigh Sisson, CFom, founder of the Las Vegas-based consulting firm O&P Insight.

Speaking at the New Jersey Chapter of the American Academy of Orthotists and Prosthetists Annual Meeting, Sisson discussed the importance of front-end and pre-billing processes, so they can avoid denials and better answer Recovery Audit Contractor (RAC) audits.

“When we talk about RAC audits, appeals and denials, it is so important to have your front-end processes and your pre-billing processes stellar so that you can answer these audits and be assured that you are not going to get a denial,” Sisson said. “Those front-end processes are so, so important.”

According to Sisson, common reasons for denial include:

  • Proof of delivery is missing or invalid;
  • Medical records are missing or do not support the need for the service provided;
  • The supplier’s records are missing or do not meet guidelines;
  • The detailed written order is missing or invalid;
  • Failing to respond to an additional documentation request; and
  • Identical or similar devices being provided during the useful lifetime period.

“We have great influence over one of these, and we are in total control, before we deliver that device, of all of the rest of these,” Sisson said.

In the event of a Medicare payment denial, Sisson recommended that providers read the documentation thoroughly, and seek assistance if they do not understand the reason for the denial. In addition, for additional documentation requests and RAC audits, it is important to read the reviewer’s notes, and request a telephone conversation with the reviewer. If a provider decides to appeal, they should do so in a timely manner and use the correct form, accurately completed.

“Also, whether it is Medicare or a private payer, make sure you follow the payer’s appeal process,” Sisson said. “If you make phone call after phone call and then you miss your appeal time, those phone calls were not official. You need to make sure you are filing those appeals on time, in the right form, every time you do it.” – by Jason Laday


Sisson L. Getting and keeping your money: Managing audits, denials and appeals. Presented at: New Jersey Chapter of the American Academy of Orthotists and Prosthetists Annual Meeting; Nov. 9, 2017; Atlantic City, New Jersey.

Disclosure: Sisson reports employment with O&P Insight.

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