Wachler & Associates Health Law BlogClaims Audits and Medical Documentation
Physicians and other clinical providers expend tremendous amounts of time and effort accurately documenting the medical care that they provide to patients. Usually, the documentation is intended to be read and understood by another physician, either the physician who created the record or another treating physician. It may also be intended to be read by billers or coders who are familiar with the practice and the type of documentation at issue. But there is another, sometimes very consequential, audience that reviews medical records: reviewers at government agencies or contractors, or commercial insurance companies that audit claims submitted by the practice.
All payors periodically audit claims submitted to them by providers. Medicare and Medicaid generally use outside contractors to perform medical review of the documentation created by providers, but may perform some review in-house, Commercial insurance companies may use a mix of contracted and in-house medical review. Generally, the payor or their contractor will request that the provider submit the medical records or other documentation that supports claims submitted by the provider, review the documentation, and issue findings, usually accompanied by a demand that the provider repay some alleged overpayment based on a deficiency that the payor will claim to have identified in the medical documentation.
The medical records review itself is often performed by nurses, coders, or others that may have a very different level of education, training, and clinical experience than the physician who created the record. Even where the reviewers are ostensibly supervised by physicians, these supervisors often have very high caseloads and rarely have the practical ability to exercise more than cursory supervision of the reviewers. It is therefore relatively common for medical reviewers to misunderstand or misinterpret the documentation they review. Extensive use of abbreviations, specialized shorthand, or clinical jargon with little context are often ripe for this type of reviewer mistake. For example, does “PCA” in a progress note mean “posterior cortical atrophy syndrome” or “posterior cerebral artery stroke”? Does a nurse reviewer with no training or experience in vascular procedures know the difference between Rutherford 3 and Rutherford III? Documentation conventions or usages that would be easily understood by another specialized clinician may not be understood by a contracted nurse reviewer with little to no training or experience in a particular specialty. More often than not, a medical reviewer that does not understand documentation will lead to claim denials.
While it is generally not practicable to document treatment in a way that is understandable to an untrained or unspecialized reviewer, physicians should be mindful of the parties who may review and critique the documentation they create. This should also be kept in mind when reviewing and appealing audit results.
Illegible handwritten notes and signatures represent a similar issue. Where a physician expends effort to enter information into a medical record, but a review cannot read it – whether because it is illegible or because the reviewer does not understand it – the effect is generally the same. The reviewer will likely act as though that piece of information does not exist and deny the claim. While there may be methods to remedy these issues when a medical review audit is performed or after claims are denied, it is generally easier and more efficient for a provider to ensure that its records and signatures are legible at the time they are created.
For over 35 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 medical review audits or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.