Q&A: Managing MUEs on clinical trial claims

Q: How do we manage Medically Unlikely Edits (MUE) on clinical trial claims?

A: MUE edits search for impossible or highly unlikely quantities, such as a claim for a toe procedure reported for eleven toes. These edits also review claims for extreme quantities of items that Medicare and other payers have deemed to be unrealistic. If such items are found, the chart should be reviewed to determine whether the extreme quantity was correctly provided. In cases where medical necessity supports that extreme quantity, the biller can override the edit and release the claim for billing. In general, however, such items will be heavily scrutinized by the payers and may be denied due to their unusual nature.

An example of an MUE that may be clinically appropriate during a clinical trial is a situation in which there is a cap of four insulin screening tests per day. In a clinical trial setting, a patient may need to exceed this limit. Either the institution will need to be committed to appealing on behalf of each patient in this situation or the study sponsor may need to be pushed to pay for the quantity of the item that exceeds the MUE limits.

Once all NCCI edits are cleared, the claim will go to the claims clearinghouse to be transmitted to the payer for payment. The clearinghouse is an outside entity that acts as an air traffic controller for the millions of claims and remittance advices transmitted back and forth between health systems and insurance companies. Medicare orchestrated the development of these entities to improve the electronic management of claims and to ensure that confidential health information is transmitted securely to insurance companies. The clearinghouse is also tasked with tracking the claim while it moves through the adjudication process.

For more information, see The Practical Guide to Clinical Trials Billing.