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Types of Chart Reviews

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So you’ve decided to implement an internal audit program for your practice.  Excellent!  There are so many external parties who can scrutinize your internal documentation, so it is a really good idea to see your practice from their perspective.  An internal audit/review is an outstanding and comprehensive tool.

The first decision is to determine what you want to get out of your audit/review.  Here are some examples of reasons to perform an in-depth, structured, peek into your own medical records:

 · “How are we doing?” review.  This is an excellent way to initiate an internal review process when you don’t have a lot of time, money, resources and have no reason to think there is anything specifically wrong.  Depending on the size of your organization, you select a very small sample:

  •  1-5 records from each provider
  •  representing a variety of services performed by that provider
  1. E/M
  2. Surgery
  3. office procedure
  4. studies
  • every piece of documentation that supports the service

 ·  Formal compliance review.  This process would follow the detailed description contained in the practice’s formal Compliance Plan.  Don’t have a Compliance Plan?  Well, that’s another blog post for another day.

 · “Someone else we know had a problem” review.  A news report or a colleague reports an awful experience with a payor or other oversight entity.  Your initial response is panic, then denial.  Eventually you realize the best path to peace of mind is to perform an internal audit/review to make sure you don’t have any of the same issues in your practice.

 · “We think we have a problem” review.  Somehow it’s been brought to your attention that one area in your operation may have documentation or compliance concerns.  An internal review can be a solid first step in determining if the problem does exist, and to determine the extent of it.

 · “We KNOW we have a problem” review.  At this point, an internal review should only be one component of a larger strategy.  Coordinating efforts with your Compliance department, and potentially Legal counsel, is imperative.  Once you’ve been alerted to a problem, the steps taken and the speed with which you correct the problem can be instrumental in mitigating consequences.

If you’ve got any questions about chart reviews, we can help.  Contact us at sue@habaneroinc.com.

Be Your Own Medical Record

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It started as a professional curiosity, but now it has become a habit, and I recommend it to everyone.  Maintain your own medical record.

I’ve found this helps me better understand what is going on with my own health, and it also makes it easier to communicate amongst the various healthcare practitioners you may see over the years.

Medical filesFor example, I recently went for a DEXA scan for bone density. It’s something that is recommended, especially for women, and especially for women with bone issues. My GYN had ordered the test, and when I went to have it done, I asked the technician for a copy of the scan and she printed it out right then and there.  Same thing when I had some 3D dental xrays taken a few months ago.  It made it easy for me to get second opinions, and eliminate a potentially unnecessary over exposure to another xray.

I suggest maintaining copies of all your blood results too.  This can help you when you are doing your own research into health related topics, be it research into traditional or alternative medical topics.

You may also want to consider doing this for any children, friends or relatives for whom you have, or may have, responsibility for.  For example, if an elderly relative were suddenly in need of medical care, would you be able to provide a list of their medications to emergency responders?

The bottom line, in today’s healthcare arena, we all need to be proactive in taking care of our health and the health of our loved ones.  As in many other areas of life, information is power!

– As published in GEM Magazine. Author: Susan Montana

Please direct your health care reimbursement questions or topics you would like to know more about to Sue@HabaneroInc.com.

The RAC Attack

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Many medical practices are feeling the impact of the Medicare Recovery Audit Contractor (RAC) process, especially as non-Medicare payors have gotten on the band wagon.  It is difficult enough to submit claims and receive payment for all the services you provide, but now they want to take back payments – sometimes years later!

What can be done to keep as much of these payments as possible?  The key is to have a formal process in place, and to be diligent about time limits and attention to detail.

What is a RAC?

Medicare began recovering overpayments from hospitals via RAC in 2005.  It began witha demonstration project in four states, and was rolled out to all providers in all 50 states in 2009.  The RAC is paid a contingency fee — a percentage of the money it recovers for the CMS.  Therefore, it is in the Contractor’s interest to cast the widest net possible.

What types of audits/reviews are there?

There are many categories of insurance recoveries.  Upon receipt of a letter from a payor, your first step is to determine the type of request.  Examples of some types of audits/review are:

  • RAC – The Recovery Audit Contractor for Region A — which includes New York — is Diversified Collection Services, Inc.
  • COB – Coordination of Benefits, where the insurer believes another party was responsible for payment of the claim.
  • Global reviews – Medicare implements a global review when sample reviews identify gross provider errors for a particular procedure code.
  • Targeted reviews – insurers and/or their contractors perform sophisticated data analyses to determine certain provider’s billing practices are outside the norm.

What should I do?

The most important thing to keep in mind is that there are very strict timeframes for responding to insurance recovery requests.  Penalties for not responding can be significant, including charging interest, and sending unpaid requests to a collection agency.

There are two schools of thought regarding a response strategy.  The first is to challengeeverything, and the second is to only challenge those cases where responding is cost justified.  There are valid arguments for each position.

Even if you do not intend to challenge each insurance recovery request, it is essential to keep copies of all letters received, and any checks or other responses submitted.  It is also recommended to keep a log of all recovery requests for quick reference.

– As published in GEM Magazine, Author: Susan Montana

Habanero, Inc., based in Patchogue, NY provides healthcare reimbursement consulting services to medical practices – helping them maximize reimbursement, maintain compliance and optimize operational efficiency. Ms. Montana may be reached at 631-244-5661 or SMontana@HabaneroInc.com.