Courtesy Calls from First Coast Service Options
- FLASCO
- September 30, 2015
- News
Courtesy Calls from First Coast Service Options
First Coast has a new team (CERT Clinical Nurse Educators) making daily calls to providers across JN regarding CERT claims that have been audited by the CERT contractor and assessed with an error. Our goal in making one-to-one education calls is to provide outreach regarding specific education related to the CERT denial. In over 90% of the cases the education relates to insufficient documentation. For example, the medical record does not support the level of service billed. And as you know with CERT it is a random sampling of claims and thus there will probably be calls regarding oncology related services.
The IOM Manual language is from the PIM Chapter 7
7.2.2.19 – One on One Education
(Rev. 550, Issued: 10-31-14, Effective” 12-02-14, Implementation: 12-02-14)
This applies to MAC and SMRC
One-on-one education places emphasis on reducing the paid claims error rate by notifying, either in writing or orally, the individual billing entities (i.e., providers, suppliers, or ordering clinician) of review findings identified on specific claims or a group of claims reviewed on probe or targeted medical review or billing patterns identified by data analysis (e.g., CBRs, OIG reports, PEPPER/FATHOM, Recovery Auditors, CERT).
One-on-one education does not include:
- Educational articles impacting nationwide issues
- Responses to inquiries on claims that were not medically reviewed by MAC MR or SMRC
- General training sessions
- POE education activities
- Speaking at society meetings
- Writing articles
