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Wrong Rates Paid by First Coast for some BLS Non-Emergencies

November 8, 2013
AAA Member Advisory
TO: AAA Membership
FROM:      David M. Werfel, Esq.
RE: Wrong Rates Paid by First Coast for some BLS Non-Emergencies

First Coast Service Options, the Medicare Administrative Contractor for Florida (and Puerto Rico and the Virgin Islands) started reducing the allowable by 10% for some non-dialysis BLS non-emergency claims. The problem appears to be limited to BLS non-emergency claims submitted with the combination of the "HE" (hospital to assisted living facility) and "GW" (transport not related to hospice benefit) modifiers. In other words it appears that only claims billed as A0428 HE GW have been affected, for dates of service on or after 10/1/13.
The problem was discovered by one of the ambulance companies in Florida on 11/7/13.  The problem has already been resolved.
Claims hitting the system on or after 11/8/13 will be paid at the correct rate.
With respect to the claims paid incorrectly, since October 1, 2013, FCSO will do an adjustment automatically. It will take approximately 30 days as they have to wait for (1) all of the claims to go through the system; (2) the two week floor; (3) a calculation of the claims in issue; (4) the internal approvals needed and then (5) make the adjustments. They do not want to have to make the adjustments more than once, so that is also why they want to make sure current claims go through correctly, etc.
If First Coast is your MAC and you have experienced this problem, keep track of the claims in issue and wait approximately 30 days for the adjustments to be done automatically by FCSO. DO NOT SUBMIT APPEALS.
If FCSO is not your MAC, check the rates you are being paid to make sure that you do not have a similar problem. This problem was the result of an error made when implementing the new rate for dialysis non-emergencies, effective 10/1/13.

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