What would happen Claims resubmitted after a clinical review of records

As part of First Coast Service Options’ (First Coast) routine data analysis process we have identified and are monitoring an increased number of providers that are cancelling and/or resubmitting claims that should be submitted via the appeals process. First Coast views this as an abuse of the process and is considering additional actions to address the problem.

The Part A claim processing system (fiscal intermediary shared system or FISS) is designed to allow providers to cancel and resubmit a claim when appropriate. The appropriate instances include those situations where a claim has been rejected due to incomplete submissions, missing information, and invalid submissions. The Part B claims processing system (multi-carrier system or MCS) is not designed to allow a provider to cancel a claim, but does allow a claim to be resubmitted if appropriate.

A claim that has been clinically reviewed and/or denied should never be resubmitted as a claim, but submitted as a redetermination.

When a letter (additional development request) is sent to your office asking for patient records, a claim has failed one of the preprogramed edits in our claims processing systems. This editing may include procedure codes, code combinations, modifiers, national or local coverage determination, billing patterns, utilization parameters, etc. Although there is provider-specific auditing ,the majority of requests are service specific and set to look at anyone billing one of the subsets mentioned above. Record reviews are completed initially by the company’s staff of clinicians or MDs in the Program Integrity department. Once a claim decision has been made to deny based on a service being “not medically reasonable and necessary,” the correct process or next step is to follow the appeals process. By following the appeals process you are given an opportunity to include attestations, signature logs, missing or omitted  records, add addenda, etc. Additionally, it allows for a different set of clinical reviewers to take a look at your records. Resubmitting the claim rather than requesting an appeal (redetermination) is considered an abuse of the program and adds additional scrutiny for medical review  to your practice by our data analysis department.