You receive a payor medical record request, and without fully reviewing the request or giving the response careful consideration, you quickly respond so that you may return to patient care. This decision can threaten your practice, your ability to receive timely payment, and your ability to continue seeing your patients. Practitioners and health care practices (Providers) face intensified scrutiny from payors, including Medicare, Medicaid, and health plans and their Special Investigation Units (SIUs). The number of medical record requests is surging, and they should not all be treated as routine paperwork. Before responding, you need to determine the type of request and who is asking for the records. Engaging an experienced health care attorney and documentation and coding compliance advisor can significantly reduce the stress of responding and impact the outcomes.
The Stakes Are Higher Than You Think
What appears to be a simple records request can quickly escalate into a high-stakes audit. Even when only 30 to 90 patient records are requested, the consequences can be severe:
- Significant Repayment Demands: Payors may extrapolate the findings, resulting in millions of dollars in alleged overpayment demands.
- Pre-Payment Review: You may be placed on pre-payment review for months to years, delaying payment while payors request and review records for submitted claims.
- Governmental Investigation or Plan Termination: Adverse findings can trigger referrals to government investigators or result in termination from the payor network, threatening your ability to see patients.
Understanding the Request
Responding to a payor medical record request is not simply a matter of gathering charts. It requires a clear understanding of who is requesting the records, what the requestor is seeking to evaluate, the applicable response deadline, and how to present the documentation accurately and effectively. Common mistakes Providers make when responding include:
- Failing to Establish a Procedure and Educate Staff: Providers should have a written procedure identifying who must be notified immediately when a request is received. Copies of the request and, when applicable, the envelope, fax cover sheet, or transmission confirmation reflecting the date of receipt, must be preserved. This information may be critical in determining response deadlines and supporting any request for an extension.
- Creating Issues Prior to Submission: Providers sometimes attempt to update or complete notes before submission without properly identifying the date and nature of the amendment. Any post-service amendment, addendum, or correction should be clearly dated and documented in accordance with applicable legal, payor, and internal policy requirements.
- Failing to Provide All Responsive Documents: Providers may submit incomplete records. For example, a progress note or daily note may be provided without the corresponding treatment plan, order, certification, consent form, or other supporting documentation. Providers may also omit collateral documentation that contains important information, such as the time spent with the patient or the medical necessity for the service.
- Delaying Extension Requests: Waiting until the last minute to request an extension creates unnecessary risk and stress. The payor’s point of contact may be unavailable, out of the office, or managing multiple requests, which can delay review and approval of an extension request.
Retaining a health care attorney experienced with responding to payor medical record requests and a documentation and coding compliance advisor will help you avoid these common mistakes and they can provide insight on the records before submission.
Pre-Submission Coding and Documentation Review
Before submitting medical records, providers should consider having a sample of the records reviewed by a certified documentation and coding compliance advisor working with experienced health care counsel. This review can help identify potential documentation, coding, medical necessity, signature, authentication, or claim-support issues before they are raised by the payor. It can also help determine whether the submission should include supplemental materials, such as signature logs, provider attestations, policies, orders, certifications, or other documentation that may address anticipated questions.
A certified documentation and coding compliance advisor brings specialized expertise in evaluating whether the records and coding support the claims at issue, which is expertise that a typical biller will not be positioned to provide. When paired with experienced health care counsel, this team can guide the Provider through each stage of the review and audit process, including assessing the scope of the request, identifying risk areas, preparing the submission, communicating with the payor, and preserving arguments for any future challenge or appeal.
Experience with payor audits is especially important because government contractors, commercial special investigation units, managed care plans, and other requestors may have different audit protocols, documentation expectations, escalation paths, and appeal procedures. Understanding those differences at the outset can materially affect how the records are reviewed, organized, and submitted.
Even if the provider receives adverse findings after submitting the records, early involvement by counsel and a documentation and coding compliance advisor ensures that the team already has the necessary background to evaluate and challenge the findings. Providers who wait until after receiving an adverse determination, or who attempt to navigate the appeal process on their own, often find themselves scrambling to retain counsel and meet short appeal deadlines. That delay can place both the provider and its response team at a significant disadvantage.
The Bottom Line
When a payor medical record request arrives, resist the urge to simply hand it off to staff and quickly respond. Take the time to seek professional guidance. A proactive response protects your practice, preserves your revenue, and allows you to stay focused on what matters most, caring for your patients.
Garfunkel Wild, P.C., and Garfunkel Health Advisors (GHA) frequently collaborate with providers to respond to medical record requests, challenge audits and reviews, and provide assistance at all stages of the process. GHA also offers services that allow providers to have their documentation and coding evaluated proactively to prepare for future audits and educate staff on best practices going forward.
Should you wish to learn more about medical coding services, you can contact Garfunkel Health Advisors by calling Simon Chaykler at 833.355.1333 or by email at [email protected].
If you wish to learn more about Garfunkel Wild’s legal services, you may contact Andrew Ko at 518.560.4025 or by email at [email protected].