Post-payment service-specific reviews
MACs resume medical review on a post-payment basis
To protect the Medicare Trust Fund against inappropriate payments, Medicare administrative contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs are resuming with post-payment reviews of items/services provided before March 1. The targeted probe and educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.
First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted 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 performs data analysis on a regular basis on all services billed to Medicare to identify services that are frequently not billed and coded correctly per Medicare guidelines. Post-pay service-specific reviews are performed based on results of a widespread data analysis that focuses on specific topics. If you bill Medicare for these services, you may receive an additional development request (ADR) letter asking for documentation. This allows First Coast to validate that you have billed the services correctly according to Medicare guidelines. Once the ADR is received, you will have 45 days to respond to the request with the supporting medical record documentation. The review will be completed within 60 days of receipt of the documentation. When the review is completed, you will be notified of the results.
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. Find tips, tools and resources for the documentation of clinical services provided to Medicare patients. Use the checklists to ensure you have met medical documentation requirements based on specific services.
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.