The appeal of claim denials after a Medicare audit can be a long and complex process. Such audit appeals generally involve large amounts of documentation as evidence, usually medical records. There are many rules governing the submission of this documentation as evidence and many strategic considerations that a healthcare provider or supplier must weigh.
Medicare audits often start with an Additional Documentation Request (“ADR”) or other type of medical records request. Medicare providers are generally required to maintain and submit to Medicare documentation that supports coverage of the services billed. However, ADRs are often difficult to interpret. They often contain boilerplate language that requests large amounts of records that do not exist or are not relevant to the services provided. On the other hand, they may use hyper technical language, the meaning of which is not clear or understood. For example, “psychotherapy notes” in this context has a very specific meaning and does not mean simply the progress notes from psychotherapy sessions.
A provider submitting records to a Medicare contractor should be aware of the practical issues. What form are the records being submitted in? Is it a form that this contractor accepts? Is there proof that the records were submitted in case the contractor later loses the records and claims none were ever submitted? If there is imaging (CT, x-ray, etc.) in the documentation, what is the quality and legibility of the copy being submitted? Often imaging that appears in high resolution in an EHR system loses resolution when printed, scanned, or otherwise transferred to the form in which it is submitted to the provider’s attorney or contractor.
Providers should also be aware that there are rules in the Medicare claims appeal process that limit the ability to submit evidence at the later levels of appeal when it could have been submitted at the earlier levels of appeal. That is, if a provider does not submit certain medical records at the earlier levels of appeal, then the provider may be barred from submitting those records at the later levels of appeal. This often comes up when the provider in the appeal must obtain records from another provider or entity, such as a referring physician or facility.
Lasty, it is important to note that nearly all documentation involved in a Medicare appeal includes protected health information (“PHI”) subject to the Health Insurance Portability and Accountability Act (“HIPAA”). Providers should work to ensure that all necessary legal and cyber security protections are in place and that such information is transmitted securely to attorneys, consultants, witnesses, Medicare contractors, and appeal tribunals.
For over 40 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to Medicare audits or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com