First Coast to Audit Therapy Claims in Puerto Rico

March 11, 2014
Rick Gawenda

On July 24, 2012, First Coast Service Options activated a prepayment edit for therapy services rendered by specialty 25 (Physical Medicine and Rehabilitation) in Puerto Rico. This was due to medical review findings that revealed this specialty presents an 88 percent error rate. The purpose of the edit is to prevent the payment of non-covered, incorrectly coded, and inappropriately billed services. Also, with medical review assistance, customer service now advises providers in correcting the billing and documentation errors.

Data for October 1 through December 31, 2013, show an error rate of 81 percent. A significant amount of this error rate is due to either non-response to requests for documentation or to the submission of incomplete documentation. These same claims on many occasions are paid at the appeals level. Although, while an increase in claims being paid on appeal is noticeable, the error rate remains high.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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