By STEPHEN SHAVER
Consultant, Wachler & Associates PC
Nearly every third-party payor of claims for healthcare services – Medicare, Medicaid plans, commercial insurers, etc. – will at some point request that the billing provider submit copies of the documentation and medical records that support the services billed. In these circumstances, an ounce of prevention is often worth a pound of cure. The payor will often make decisions regarding coverage and overpayment allegations based on the records submitted by the provider. The provider can proactively address or even prevent many disputes by careful attention to their response to the medical records request.
First, a provider should be aware of what entity issued the request, what specific records it has requested, and for what purpose. For example, a Medicare Unified Program Integrity Contractor (“UPIC”) is charged with investigating allegations of fraud within the Medicare program and may conduct a records review differently from other Medicare contractors. The Special Investigation (“SI”) unit or team at many commercial insurers serves much the same function. The provider is generally required to comply with the request for records, whether by law, regulation, or contractual agreement. It is, therefore, important to carefully review the record request and provide documentation that is responsive. Where the request includes vague or over-broad requests, or contains unclear terms of art, it may be appropriate to contact the requester and clarify the request. When the request includes records held by third parties, such as billing companies or other providers, the provider receiving the request will generally be required to gather those records from third parties. This process can be time-consuming and should be started early.
Second, the provider should be aware that the medical records may not necessarily be reviewed by someone with the same education, experience, or expertise as the provider. In fact, it is often quite the opposite. Medicare and Medicaid generally use outside contractors to perform medical reviews of the documentation created by providers but may perform some reviews in-house; commercial insurance companies may use a mix of contracted and in-house medical reviews. The medical records review itself is often performed by nurses, coders, or others who may have a very different level of education, training, and clinical experience than the physician who performed the services, made patient care decisions, and created the records. Even where these reviewers are ostensibly supervised by physicians, these supervisors often have very high caseloads and rarely have the practical ability to exercise more than just a cursory supervision of the reviewers. It is, therefore, relatively common for medical reviewers to misunderstand or misinterpret the documentation they review. For example, does “PCA” in a progress note mean “posterior cortical atrophy syndrome” or “posterior cerebral artery stroke”? Does a nurse reviewer with no training or experience in vascular procedures know the difference between Rutherford 3 vs Rutherford III? It may be clear to an experienced practitioner, but not to the reviewer.
Documentation conventions or usages that would be easily understood by another specialized clinician may not be understood by a contracted nurse reviewer with little to no training or experience in a particular specialty. More often than not, a medical reviewer that does not understand documentation will lead to claim denials. While it is generally not practicable to document treatment in a way that is understandable to an untrained or unspecialized reviewer, physicians should be mindful of the parties who may review and critique the documentation they create. This should also be kept in mind when reviewing and appealing medical review results. At the record request stage, a provider may consider including a list of common acronyms or other explanations.
Illegible handwritten notes and signatures represent a similar issue. Where a physician expends effort to enter information into a medical record, but a review cannot read it – whether because it is illegible or because the review does not understand it – the effect is generally the same. The reviewer will likely act as though that piece of information does not exist and deny the claim. At the records request stage, a provider with illegible notes or signatures may consider submitting signature logs or attestation along with the records or, in extreme cases, submitting legible transcriptions of the medical records.
A provider submitting records pursuant to such a request should also be aware of logistical issues of submission. What form are the records being submitted in? Is it a form that this payor or contractor accepts? Is there proof that the records were submitted in case the reviewer later loses the records and claims no records were ever submitted? A common issue concerns copies of imaging (CT, x-ray, etc.) that support the services at issue. Often imaging, that appears in high resolution in an EHR system loses resolution when printed, scanned, faxed, or otherwise transferred to the form in which it is submitted to the provider’s attorney or to the reviewer. A provider should be careful that the copies of the records that are submitted to the reviewer are of sufficiently high quality to be useful. Claims that are otherwise covered and defensible may be denied because the copy of the imaging that was submitted to the reviewer was too blurry to show anything useful.
Certainly, not all claim denials or reviewer issues can be addressed up-front in response to a medical record request. However, careful review of the records, attention to issues, and the submission of a more comprehensive response can often be a useful tool to narrow the issues on review and save the provider time, effort, and resources in appealing or litigating the dispute later.