Industry News: Florida

In May 2011, First Coast Service Options (FCSO) began accepting fax requests for reopenings of claims with dates of service in January-May 2010 to be reprocessed under the Affordable Care Act (ACA). Since that time, mass adjustments have been executed that automatically reprocess claims where the billed amount was greater than the new (post-ACA) allowances. To reduce workloads and costs associated with manually reprocessing faxed requests, CMS has authorized contractors to stop performing manual reopening of those claims that are scheduled to be mass-adjusted.

Medicare will only pay for tests that meet Medicare’s reasonable and necessary guidelines. Medicare may deny payment for a test that the physician believes is appropriate but does not meet Medicare’s definition of “medical necessity.”

The Office of the Inspector General (OIG) recommends that laboratories and laboratory companies take the following precautions to help ensure that requirements for medical necessity are met:

In order to enhance Medicaid efforts to ensure that the program is providing quality, affordable health care for all Americans, the United States Congress included provisions in the Patient Protection and Affordable Care Act of 2009 that mandates changes in Medicaid rules for enrolling providers and submitting claims. Starting January 1, 2011, Medicaid will require that all providers who must obtain an NPI include their NPI on all claims submitted to Medicaid. This will include all claims from these providers, whether submitted on paper or electronically.

An article published in the January 2010 Medicare B Update (page 51) of the publication may have led providers to a misunderstanding regarding the correct use of modifier CB (Service ordered by a renal dialysis facility [RDF] physician as part of the ESRD (end-stage renal disease) beneficiary’s dialysis benefit, is not part of the composite rate, and is separately reimbursable).

Medicaid is dedicated to protecting your personal information against fraud and scams. You can help protect your license and personal bank accounts by being cautious in giving out your own personal information such as first name, last name, business name, email address, userid/password, financial information (credit card, bank account number, PIN), social security number, and driver's license number. We will never request personal credit card or bank account information over the telephone.

First Coast Service Options Inc. (FCSO) has been made aware of an issue regarding providers receiving denials when billing CPT code 84295 (Sodium; serum, plasma or whole blood) and ICD-9-CM code 585.6 (End-stage renal disease) for hemodialysis patients when modifiers CB and CF and several other modifiers identified for the automated multichannel chemistry tests (AMCC) were appended that noted the service rendered were outside the composite rate.