Physician practices are inundated with requests for medical information of every nature: encounter note copies, health and life insurance authorizations, managed care referrals, handicap parking certificates – forms to sign, forms to copy, forms to mail out … it is a never-ending stream of administrative requests all based on medical record (MR) documentation. Documentation, whether paper-based or in electronic form, is critical to the long-established and far-reaching responsibilities of the modern physician practice.
It is also from documentation that oversight entities for federal and state programs under the Centers for Medicare and Medicaid Services (CMS) like Medicare and Medicaid audit physicians and ultimately approve or deny services, take back monies, suspend claims in pre-payment reviews, levy fines, and even prosecute providers. In an arena where so much MR documentation is created, handled, processed and managed, it is a surprise to many providers that judgments issued by official entities such as “no documentation submitted,” “lack of documentation to support services billed” and/or “documentation does not indicate medical necessity of the service” tend to be the most prevalent reasons for provider service denials and stern repayment demands.
Physician practices have long received MR requests from its local Medicare carrier (Medicare Administrative Contractor or “MAC”) and/or state Medicaid entity; these promise to increase as the government tightens its grip on fraud, waste and abuse. One high profile initiative under the Comprehensive Error Rate Testing (CERT) program oversees each Medicare Administrative Contactor’s payment systems and originates MR demands called Additional Documentation Requests (ADRs). Providers can expect to see these requests grow exponentially. More recently the Recovery Audit Contractor (RAC) initiatives are beginning to sound familiar to many providers. Physicians can certainly expect RAC requests for MRs to be a part of the norm going forward, with such requests being issued as early as every 45 days, going back to services beginning Oct. 1, 2007, with ceiling limits for MR request quantities depending on the size of the practice.
The track record for success under these mounting requests and ADRs thus far, by the typical provider, is less than stellar. The RAC enterprise, recognized now by the federal government as both quite imposing and uncovering potential high risk areas of organizational “vulnerability” because of the enormous quantities of MR demands being sent to providers, has recently been addressed in part by CMS in an article via the Medicare Learning Network (MLN) in MLN Matters article SE1024 in late July 2010. Though addressed to inpatient hospital and skilled nursing providers, it has implications and lessons for physicians as well. Addressing “RAC high dollar improper payment vulnerabilities,” CMS has issued warnings that provider vulnerabilities lie in “(1) non-compliance with timely submission of requested medical documentation and (2) insufficient documentation that did not justify (the) services billed, were medically necessary and/or (were) correctly coded/billed.”
However, that issuance was only a warning and the situation can be remedied; providers should not forfeit hard-earned, legitimate revenue in repayment demands back to the federal and/or state entities because of such “vulnerabilities.” Simply put, in many physician practices there are no internal administrative structures or response mechanisms set up in an intelligent way to process, track and manage these all-important MR requests. Now, with the RACs gearing up for medical necessity and complex visit reviews thereby set to increase their MR requests, providers should take this opportunity to establish an internal MR request management system.
How does the average physician practice operating under typical administrative processes, already burdened with excessive documentation demands, exert a measure of control and compliance over the numerous federal/state MR demands, and keep from becoming overwhelmed with these official requests? Establishing a simple but effective three-step enterprise to manage this growing aspect of routine physician administration is tantamount to success. The three steps in this process are: (1) establish straightforward, methodical protocols for the receipt, processing, tracking and fulfillment of all official MR requests; (2) appoint an internal MR request “response team” to handle and manage these requests; and (3) perform post-fulfillment analyses of each request, reviewing the final adjudication of each audit case to assess potential influence on clinical operations (e.g., documentation), administrative processes (e.g., coding) and/or negative impact on revenue.
Establish Protocols for Managing MR Requests
Whether set up via a paper-based system or via eHR software (with automatic chart flagging/tracking functions), protocols should be established to respond to all federal and state MR demands. Protocols should administer various aspects of the MR request fulfillment process in a premeditated and thoughtful way, avoiding a reflexive response that might adversely influence practice staff. Such knee-jerk responses can cause personnel to hurriedly fulfill these important MR demands just to get them done and out the door, perhaps overlooking critical aspects of the documentation that might otherwise save the cases from turning into downcoded or denied encounters with repayment demands from Medicare or Medicaid. The protocols should include steps for: (a) receipt and logging of all official MR demands; (b) retrieval of charts and culling of pertinent date-of-service (DOS) information; (c) inspection and final verification of the information to be sent; (d) copying the documents; and (e) mailing the requested information by certified means. Such protocols also entail internal monitoring and tracking the fulfillment process along the way, as well as having an analysis and response mechanism at-the-ready when the practice receives the final judgment of each audit case.
An important consideration for physician practices with multiple locations is centralization: will this fulfillment process be centralized, working through one appointed MR request response team, or will there be a team in place at each of the practice locations? A plan of action in these scenarios is essential.
Forming the MR Request Response Team
Forming a MR request “response team” for official MR demands is a smart thing to do. Even in the smallest of physician practices, in which the physician would play an active role on the team, a highly effective team can be appointed. There are four main elements of the response team with various assigned duties that can be mixed and matched, comprised of: (1) Practice Manager – responsible for overseeing the entire process and ensuring internal compliance as well as performing post-fulfillment analyses; (2) Administrative Leader – responsible for ensuring all administrative personnel assigned to the team perform their functions and performs final inspection and verification of all submitted audit packages; (3) Clinical Leader – responsible for reviewing all culled clinical data to ensure appropriateness and accuracy of the data, e.g., demonstration of medical necessity, data from earlier episodes such as an earlier review of systems questionnaire influencing the DOS under audit etc., and (4) Medical File Clerk or Medical Secretary – responsible for receiving (via the office mail) and logging the official MR demands, pulling the charts, initially culling the targeted MR documents from the chart, routing the chart to the next level (i.e., Clinical Leader for clinical data verification), and receiving, after final approval for copying and certified mailing, the various chart documents selected to fulfill the official MR request. This person, if he/she is responsible for opening/routing the practice mail, will also direct all post-fulfillment adjudications to the Practice Manager for appropriate follow up. Obviously, if other persons are responsible for retrieving and opening/routing the daily mail, those persons would be injected into this process at the appropriate points. Alternates should be appointed as well in the case of staff vacations, absences, etc. This is a highly flexible arrangement of roles and responsibilities, and can be constructed in many different ways depending on the size, staffing and physical location(s) of its various team members.
Performing Follow-Up Analyses
Post-fulfillment analysis of each case must be performed; it is essential the physician practice leaders view each final ruling by the overseeing entity (e.g., CERT or RAC) as an opportunity for growth and possible reorganization of duties. This can include necessary modifications in documentation (techniques, processes or quality of information), coding fortification, improved billing standards, or all of these items. This might also include opportunities to appeal the decisions, which should be carried out if the encounters in question have been misjudged or assessed prematurely in some crucial way, e.g., specific documentation was not available and therefore left out of the original audit package, or a signature log or physician attestation is needed to authenticate the documents after-the-fact, etc. The various audit types will lumber under different assessment rules and appeal rights for the provider. Physician practices should be aware of the various rules under MAC, CERT and RAC audits. Negative impact on revenue should be viewed with a critical eye and questions asked: Are the MR requests resulting in denials with attached repayment demands for simple services that, if documented with higher quality or coded more accurately, would be approved and paid? Opportunities for internal practice growth may not always be obvious, but even minor documentation and/or coding changes can potentially save the practice thousands of dollars annually.
The ubiquitous and ever-growing number of Medicare and Medicaid MR requests sent out to physician practices should be treated the same way an IRS federal tax audit financial records request would be treated: with great care, attention to detail and inspection of all documents copied and sent. Once the requested records have been mailed to the entity, each practice should anticipate receipt of final results or judgments on every case and perform appropriate follow up actions to correct functional inadequacies in practice administration, clinical operations, or coding and billing.
Michael G. Calahan is an independent health care consultant working in the Washington DC Metro area. He specializes in compliance, revenue cycle management, CDI, coding, and billing in the physician, facility inpatient/outpatient arenas. He may be contacted by e-mail at firstname.lastname@example.org.