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Last Modified: 1/18/2018 Location: FL, PR, USVI Business: Part A, Part B


“The PDS report was excellent. It was quite informative. It broke out what claims were sent in, those that were approved and those that were denied.”

-Tracie L. Jones MHA, CPC
Director Revenue Cycle

Click here and tell us about your success story with First Coast’s web tools.

Eliminate denied claims with SPOT and First Coast’s web tools

Finding a letter in the mail from a Medicare administrative contractor (MAC) might seem daunting for some health care providers. The message sealed inside could mean a number of things. But for Tracie Jones and her Medicare billing team at Simon-Med-Florida, the postman delivered an unexpected gift in March.
“We received a letter from First Coast stating that more than 10 percent of our claims were being denied,” Jones said. Because Medicare beneficiaries represent about 40 percent of the patients treated at nine Simon-Med facilities in the tri-county region of Orlando, the action taken to improve its billing practices, as a result of the letter, is paying off in a big way.
Each month, First Coast Service Options (First Coast), the MAC for Florida, Puerto Rico, and the U.S. Virgin Islands, contacts providers with high volumes of preventable Medicare claim errors. The letter directs providers to pages on the First Coast website, where providers can access problem-solving tools such as First Coast Service Options’ Secure Provider Online Tool (SPOT), First Coast University, and information about avoiding return unprocessable claims (RUC).
“After reviewing the letter, I went to the First Coast site to get to the bottom of what was causing problems with our billing. One of the first things I did after receiving the letter was set up a SPOT account,” Jones said. SPOT is a portal where medical providers can electronically view and correct Medicare claims.
“Once we had access to SPOT, I went in and pulled the first two months of claims data through the PDS report,” Jones said, referring to the provider data summary (PDS). Most, if not all, of the denial codes were related to routine ultrasound tests and preventative exams. One procedure with an extraordinary high number of denials was DXA, a bone density test for measuring bone mineral density that is only covered by Medicare once every two years, Jones said.
The PDS report helps providers identify recurring billing issues through a detailed analysis of billing patterns in comparison with those of similar provider types during a specified time period. “There were 10 message codes which made up 90 percent of the denied claims we were experiencing,” Jones said “We found that our billing company had been coding tests incorrectly. We also found that our scheduling department was scheduling DXA tests for patients sooner than Medicare coverage would otherwise allow. “We were leaking money. We had a puzzle we needed to take apart and reassemble to see where the leaks were.”
The PDS includes comparisons of volumes and percentages of services in claims designated as paid, denied, duplicate, processed (subtotal), and RUCs that were submitted by the provider or the provider’s peers during the specified time period. “The PDS report was excellent. It was quite informative. It broke out what claims were sent in, those that were approved and those that were denied,” Jones said.
To confirm her interpretation of the data from the PDS report, Jones then called the provider relations representative phone number listed on the bottom of the letter. She reached Mary Pita Carrazana of First Coast and together they reviewed the problematic reason codes and other information from the PDS report.
Carrazana suggested they check one of the procedure codes in question, Current Procedural Terminology (CPT®) code 77085, on the local coverage determination lookup tool. “I walked with Tracie through the LCD look up tool to review the procedure code and we found that the DXA procedure was covered once every two years,” Carrazana said.
Using the data from the report, Jones said they educated their third-party billing company about the errors and how the claims were being coded incorrectly. Then we worked with our scheduling department to make sure we were only performing the DXA test according to Medicare guidelines,” said Jones.
Though they only recently implemented process improvements, Jones says she is already seeing positive results. “I’ve looked at our June accounts receivable report. I can already see where it’s improving the bottom line.”
After diagnosing the original issues with their billing, Jones says she will continue to access PDS reports on a regular basis as a part of a more robust compliance program. “Being proactive is always better. The PDS report is like a free self-audit. It’s very smart. The fact that it’s free shows Medicare wants you to do a good job with your billing.”
Carrazana agrees the tools can be an effective part of a provider compliance program. “Providers that use vendors or third-party billing services are sometimes not aware of their claim denials. Ultimately the provider is responsible for all claims submitted under their provider number. And, use of the First Coast web tools we emphasize in our focused education efforts can be an effective way for providers and their vendors to stay on top of any issues,” Carrazana said.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.