01/17/2018

95% of MMO DME Denials Reversed

As previously indicated on January 3 of this year the OSCA spoke with Medical Mutual’s Chief Executive Officer and their Vice President of Legal Affairs & Assistant General Counsel regarding the company’s denial of members’ claims when it comes to durable medical equipment. At that point in time the company informed the OSCA they would halt a project in which they denied claims for DME’s (January 3rd, 2018 Press Release).

As conversations continued with MMO it was confirmed today by a senior financial investigator at MMO that 95% of the denials have been reversed and have been approved for payment. Per the senior financial investigator “this is a recent development and the individual DCs, in most cases, will not yet have this information but they will be receiving it in the next 2 weeks.”

Additionally it was confirmed that contracting and/or addendum requirements did not lead to these denials. In the case of a utilization review prompting a denial of a service, the first step is for the provider’s office to initiate a PAR (physician action request.) This is the first level of appeal and would allow the DC to provide documentation specific to the service to support medical necessity.

If, after receiving the upcoming EOBs/explanation of review, you find yourself in the smaller percentage of claims that are still denied and would like some assistance, you may reach out to the OSCA. MMO has expressed a willingness to speak with us regarding the specifics of individual provider cases.

The OSCA has their next meeting with MMO next week to further discuss concerns regarding the use of modifiers and associated denials.

For additional information please contact Dr. Brandy Spaulding at brandy@oscachiro.org