Last Modified: 11/11/2020
Location: FL, PR, USVI
Business: Part A, Part B
Q. How did I get selected for post-payment service-specific review?
A. The Centers for Medicare & Medicaid Services (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 coded, and medically reasonable and necessary.
First Coast is resuming fee-for-service medical review activities beginning August 17. First Coast will be conducting post-payment review of items/services known to frequently be not billed and coded correctly per the Medicare guidelines for dates of service before March 1. Providers selected for service-specific review were identified by data analysis of having billings for the identified service(s) before March 1.
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.