Home Health & Hospice Week

Stay on top of audit requests so you're able to meet all request deadlines.

Medical reviewers can retroactively deny your claims for a number of reasons -- but one that you should remedy is lack of medical documentation.

You could get hit with medical review from a variety of sources these days -- Medicare Administrative Contractors, intermediaries, Program Safeguard Contractors, Zone Program Integrity Contractors (ZPICs), Recovery Audit Contractors, etc. If a medical reviewer from one of these contractors requests your medical documentation and you don't send it -- or you submit incomplete or illegible records -- your payments can be denied. Plus, money that your MAC or intermediary already sent to you can be recovered in cases of nonexistent or incomplete documentation.

The Centers for Medicare & Medicaid Services recently identified the issue of incomplete documentation as a "high dollar improper payment vulnerability," and the agency issued MLN Matters article SE1024 to discuss the topic and explain to providers that documentation should be a top priority.

Staff "should be catching insufficient documentation before a claim leaves the office, but in some cases, it's caught by RACs on the back end -- after a claim has already been reimbursed," says Atlanta-based consultant Jay Neal. "If you know you're missing documentation, you really shouldn't bill for the service in the first place, or you could have to reimburse that money down the road."

Your organization isn't the only party in the RAC-provider relationship that has to play by the rules. The RACs are required to stay within the following guidelines when requesting documentation from medical providers, according to the MLN Matters article. The RAC must:

• indicate the deadline by which you have to submit your medical records.

• contact you one additional time before denying your service based on lack of documentation.

• accept and review extension requests if you can't submit your documentation in a timely manner.

• suggest which types of documentation will help its employees adjudicate the claim.

• accept medical records on CDs, DVDs, or via fax.

• limit its claims look-back period to three years, with a maximum look-back date of Oct. 1, 2007.

• limit the number of medical requests every 45 days.

• indicate the status of the provider's additional documentation request on its claim status website.

• maintain a provider web portal where providers can customize their address and find the correct point of contact.

• post all approved issues under review on its website.