Steven Baruch - Health Care Compliance Association

More documents

Recommendations

Info

focus feature Federal medical record requests: Setting up a RAC & CERT Response Team By: Michael G. Calahan, PA, MBA December 2010 38 Editor’s note: Michael G. Calahan is currently the Director of Physician Services at Kforce Healthcare, Inc., working in the Washington, DC Metro area. He specializes in compliance, revenue cycle management, clinical documentation improvement, coding, and billing in the facility and physician arenas. He may be contacted by e-mail at mcalahan@kforce.com. There was no avoiding it: a federal RAC request for medical records (called an Additional Documentation Request or ADR) had arrived in the afternoon mail. The letter was passed around the office, starting with the mail clerk and then to the lead coder, next to the coding manager who propped it up on her monitor as a reminder to hand it off to the clinic director, until finally it ended up in the director’s inbox several days later. The director had known this was imminent, but did not anticipate having to handle the scenario today, while three key staff were out on vacation, the clinic physicians were busy with full schedules as usual, and her most trusted administrative assistant was fulfilling his last day of employment in the clinic. In a rush to get the request completed and returned (“out of sight, out of mind”), she hastily pulled the requested records herself, decided which medical record (MR) notes were to be copied, passed off the copying to the unit secretary and, within 30 minutes, completed the entire task. She affixed a stamp to the return envelope and dropped the “audit package” into the outgoing mailbox. Whew, that was that! Or was it Let’s start at the beginning. Facilities and physician practices are inundated with requests for medical information of every nature: clinic visit notes, health insurance authorizations, managed care referrals, handicap parking certificates, forms to sign, forms to copy, forms to fax, etc. It is a never-ending cycle of administrative requests, all based on the foundation of the health care encounter: medical record (MR) documentation. Whether paper-based or in electronic form, MR documentation is critical to the long-established and far-reaching responsibilities of modern health care providers. Coincidentally, MR documentation is also the source used by oversight entities that work with the Centers for Medicare and Medicaid Services (CMS) to audit providers and ultimately approve or deny services, take back monies, suspend claims in pre-payment reviews, perform probe audits, levy fines, and even prosecute providers. In an arena where so much MR documentation is created, processed, and maintained, it is a surprise to find that judgments such as “no documentation was submitted,” “documentation was not received by the due date,” “missing documentation in support of services billed,” and/or “documentation does not indicate medical necessity” tend to be the most prevalent reasons for provider service denials and stern repayment demands. The demand for reviewing MR documentation is only set to increase. The high profile initiative called the Comprehensive Error Rate Testing (CERT) program oversees each Medicare Administrative Contactor’s (MAC’s) payment history and originates MR demands to providers. The MACs likewise perform pre-payment and post-payment reviews, requesting MR copies for everything from complicated inpatient stays to non-physician practitioner (NPP) office visits. More recently, the Recovery Audit Contractor (RAC) initiatives have become a familiar part of the health care landscape. Providers should expect RAC requests for MRs to be a part of the norm going forward, with such requests being issued as often as every 45 days and reaching back to services provided as early as Oct. 1, 2007. The ceiling limits for MR requests are dependent on the type/size of the facility or physician practice (in volume of claims or in number of providers). All of these oversight programs promise to increase as the government tightens its grip on fraud, waste, and abuse. Unfortunately, the track record for success under these mounting documentation requests is less than stellar, if official reports by local MACs and the CERT bodies are correct. The RAC enterprise is Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
ecognized now by the federal government as capable of causing and/or uncovering potential high-risk areas of organizational “vulnerability” because of the enormous quantities of MR demands set to be sent to providers. To this extent, responses to RAC requests have recently been addressed in part by CMS in an article via the Medicare Learning Network. 1 Although it is addressed to inpatient hospital and skilled nursing providers, the article has implications and lessons for all providers. Addressing “RAC high dollar improper payment vulnerabilities,” CMS issued warnings that provider vulnerabilities lie in (a) non-compliance with timely submission of requested medical documentation and/or in reply to a RAC request that (b) insufficient documentation … did not justify services billed, [did not justify the] medically necessary and/or [were not] correctly coded/billed.” The situation can still be remedied, however. Providers must ensure that specific internal administrative structures or ADR response mechanisms are set up to process, track, and manage the numerous federal MR requests. Now, with the RACs gearing up for full-blown facility and physician medical necessity and complex reviews (thereby set to increase the number of MR requests), providers must take this opportunity to establish an internal MR request management system. How does the typical provider, whether a facility, clinic, or physician practice, set up such a system Establishing a simple but effective three-step approach to manage the requests is tantamount to success. The three steps are: n Establish straightforward, methodical protocols for the receipt, processing, tracking, and fulfillment of all official MR requests; n Appoint a flexible MR request “response team” to handle and manage these requests; and n Perform post-fulfillment “impact” analyses of each request’s outcome, reviewing the final adjudication of the cases audited to assess fiscal impact on clinical operations (e.g., improved documentation), technical processes (e.g., more accurate coding), as well as any negative impact on revenue. Establishing methodical protocols Whether set up via electronic health record (EHR) software (with automatic chart flagging/tracking functions) or via a paper-based system, oversight protocols should be established to respond to all official MR demands. Protocols should administer various aspects of the fulfillment process in a premeditated and thoughtful way, avoiding a pervasive reflexive response that might adversely influence staff when processing these MR requests. Such knee-jerk responses can cause personnel to fulfill the MR demands in a hurried manner (e.g., the opening example in this article) just to get them completed, perhaps overlooking critical pieces of documentation that might otherwise save the claims from being downcoded or denied with resultant repayment demands. The oversight protocols should include steps for: n receipt and logging of all official MR demands; n retrieval of charts and culling of pertinent date-of-service (DOS) information; n inspection and final verification of the information to be copied and sent; n copying the documents; and n mailing the requested information by certified means. An important consideration for facilities, clinics, and physician practices with multi-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 facility locations Once the requests have been fulfilled, a plan of action for communicating audit results back to a central point within the health care system or within the multi-office physician practice might be essential for fiscal controls. A flexible MR request response team From any perspective, forming a MR request response team to exert control over federal MR demands simply reverberates with intelligence. 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 created. Four main appointments of a MR response team, with various assigned duties that can be mixed and matched, should be accomplished: n Clinic director or practice manager – responsible for overseeing the entire process and ensuring internal compliance as well as performing post-fulfillment analyses; n Administrative leader – responsible for ensuring all administrative personnel assigned to the team perform their functions and for performing final inspection and verification of all submitted audit packages; n Clinical leader – responsible for reviewing all culled clinical data to ensure appropriateness and accuracy (e.g., demonstration of medical necessity and inclusion of prior visit documentation influencing the date-of-service under audit, etc.,); and n Unit secretary, file clerk, or medical secretary – responsible for opening and logging the official MR demands from the mail, pulling charts, performing an initial round of culling the identified MR Health Care Compliance Association • 888-580-8373 • www.hcca-info.org Continued on page 41 December 2010 39
Page 1 and 2: Volume Twelve Number Twelve Decembe
Page 3 and 4: Publisher: Health Care Compliance A
Page 5 and 6: for the nurse with the bad back, th
Page 7 and 8: Mobility disabilities: A technical
Page 9 and 10: RACs are coming to Medicare Advanta
Page 11 and 12: an attestation statement for the pu
Page 13 and 14: Social Networking John Falcetano Ed
Page 15 and 16: SB: I am the first full-time, dedic
Page 17 and 18: If you have any questions that you
Page 19 and 20: I called Joe Murphy, and before I t
Page 21 and 22: Once these steps are completed, the
Page 23 and 24: of 2010 (PPACA) and the Health Care
Page 25 and 26: 100% Why is Compliance not a part o
Page 27 and 28: Routine meetings should be set up s
Page 29 and 30: COMPLIANCE 101 Stark and academic m
Page 31 and 32: total compensation of the referring
Page 33 and 34: teaching hospitals, medical schools
Page 35 and 36: providers who participate in the Me
Page 37: Health Care Compliance Association
Page 41 and 42: Federal medical record requests: Se
Page 43 and 44: medication and services previously
Page 45 and 46: individual accountability provision
Page 47 and 48: created inappropriate financial inc
Page 49 and 50: New HCCA Members n Coquette O’Rou
Page 51 and 52: • Internal Audit • Litigation S

Steven Baruch - Health Care Compliance Association

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?