Last Modified: 10/28/2022
Location: FL, PR, USVI
Business: Part A, Part B
Q. How did I get selected for post-payment service-specific review?
A. CMS continually strives to reduce improper payment of Medicare claims per Social Security Act Sections 1833(e), 1815(a), 1862(a)(1)(A) and 1842(p)(4). As a Medicare administrative contractor (MAC), First Coast is tasked with preventing inappropriate Medicare payments. Contractors use data analysis as the foundation for detection of aberrancies or patterns of apparent inappropriate billing, which may be potential claim payment errors. Data analysis is the comparison of claim information and other related data to identify potential errors. Various sources of information and techniques are used to identify potential errors that pose the greatest financial risk to the Medicare program. When such aberrancies or inappropriate billings are identified, additional measures are taken to verify and add context to the data. One of the ways this is verified is through medical review of claims. Medical review of claims helps to ensure that Medicare pays for services that are covered, correctly billed and coded per the Medicare guidelines, and medically reasonable and necessary.
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