• Records requests: Answer carefully

    Your practice probably receives multiple requests for records each week. Unfortunately, more and more of these requests are related to your claims for payment. With ever-growing reports of waste and abuse in health care and profits to be made in recovering money paid to physicians and other providers, these requests are not going away. Whether from Medicare administrative contractors (MACs), recovery audit contractors (RACs), Comprehensive Error Rate Testing (CERT) program contractors, private payers or Medicaid plans, how your practice responds to these requests can make a big difference in your practice's financial future.

    So the first question is, who responds to these requests in your practice? Do they understand the importance of sending the right records to support the services billed and doing this in the time period specified on the request? Many of you may be familiar with the CERT program that the Centers for Medicare & Medicaid Services (CMS) commissioned to review the accuracy of claims paid by their Medicare contractors. Some of the most common reasons for errors in the program are these:

    1. Records not sent.
    2. Records sent but not for dates or services billed.
    3. Records illegible or unsigned.

    If your practice doesn't provide the records to substantiate your charges, the claim is found to have been paid in error. Medicare contractors are obligated to recover money paid in error. Auditors working for private payers are incentivized to recover money paid in error.

    The second question is whether you have a process for making sure that all documentation is provided to support the charges in question. If not, it is probably time to implement one. Here are some tips that might help:

    • Identify a primary and back-up staff person to receive all records requests related to claims or payment.
    • Create a log identifying the date the request was received, the type of records requested and the date the records were sent.
    • If there is any question whether documents are legible or sufficient to support the services that were billed, the physician or other provider of services should review the records and provide a transcribed copy of the documentation in addition to a copy of the original documentation and/or a letter explaining any additional information that may have bearing on the outcome of the review. (Any addendum to the original documentation should be signed with the current date added.)
    • Create a checklist to be used in confirming that copies are ready to be mailed.

    Establishing a formal process for responding to requests for records may provide a framework for ensuring that all are appropriately and efficiently handled and help to identify recurring gaps in documentation. It may also protect money already paid to you as well money that you are due.

    There are already too many opportunities for practices to lose money in the insurance billing process. Most practices can't afford to take lightly efforts by Medicare and others to recover money they have already been paid.

    Posted on Sep 25, 2009 by Cindy Hughes

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.