September 26, 2024
The Reimbursement Team at Hancock, Daniel & Johnson, P.C. provides legal representation to providers and health systems embroiled in disputes with government and private payors. When these stem from audits, our clients often come to us immediately to assist in responding to record requests, but it is sometimes appropriate for a provider to handle the initial production internally. In those cases, we provide the following tips to avoid common mistakes in responding to an auditor’s request for records and to maximize the opportunity for good audit results:
- Start early to respond to a request for medical records. As soon as a notice of an audit and request for documents is received, develop a plan for responding. The process is time-consuming and could require multiple reviews of medical records.
- Identify who is conducting the audit and note when the audit is being conducted by a governmental regulatory body that typically reviews for fraud, waste, and abuse. In those situations, it may be best for Hancock Daniel’s Reimbursement Team to help navigate the document production.
- Determine, if possible, what issue is under audit. Is it medical necessity, E&M code leveling, or something else? This will help determine whether to produce more records than those requested. For example, if the audit involves a medical necessity review, a clinician should be involved in identifying which records to submit because proving medical necessity may require a review of records before the date of service at issue and not just the office note from that date.
- Make note of the deadline for submitting the records. If necessary, request an extension and be sure to get the extension in writing. Do not miss the deadline for submitting the records. Missing deadlines can result in procedural defaults and force the provider to defend an overpayment and recoupment request. It can also unnecessarily force the provider into the appeals process, which can be expensive and time consuming.
- Collect the records and do not send the request to a medical record vendor. Responding to an auditor’s medical records request is different than responding to a request made for other purposes and it should not be put in the hands of a record vendor.
- Once the records are collected, ensure they are complete. One of the most common errors providers make is sending incomplete records. This can have devastating consequences because the auditor may conclude that the records do not exist and/or the care was not provided and refer the matter to regulatory bodies to consider whether there is fraud, waste, and abuse.
- Do not include extraneous or irrelevant records. Do not send the entire electronic medical record unless it is requested. Sending unnecessary records such as nursing flowsheets and administrative forms can complicate the review process and potentially raise questions about compliance practices.
- Be sure the records are legible. The goal is to make it easy for the auditor to find the information in the records that justifies the claim paid for that service. Do not submit a printed and scanned copy of the records because they are often illegible, and the auditor will have a more difficult time finding the necessary information.
- Organize the records. Do not send a pile of unorganized records without any context or explanation. This can make the audit process needlessly challenging. Organize and label records in a logical manner that demonstrates the office is managed well, has a commitment to regulatory compliance, and can be trusted to provide accurate claims for payment.
- Review the records for any potential issues that the auditor may find. Identify any errors (incorrect patient or date of service) or omissions (missing signatures). Never modify or alter records in response to audit requests. It is imperative to maintain the integrity of the medical records and produce them in the original, unaltered state. Any attempts to manipulate, falsify, or add documentation can create exposure to severe legal consequences. While records cannot be altered, any issues can be identified and explained to the auditor in the cover letter to mitigate potential concerns. This review can also reveal risk exposure and provide information about whether to engage legal counsel before submitting the records.
- Draft a cover letter to send with the record production. Include sufficient information that identifies the date of the records request, the date the records are submitted, and a description of what records are being submitted. In the cover letter, send a message of transparency to the auditor. Avoid any defensiveness or indication that you do not want the auditor to see the medical records. They have a right to see the records that support your claims, either through regulations or by contract.
- IMPORTANT. Keep a copy of the cover letter and a complete copy of the exact records produced in case an appeal is necessary in the future.
- When the audit results are received, review them and if an overpayment is noted, immediately contact a member of Hancock Daniel’s Reimbursement Team to help determine whether an appeal would be appropriate.
Click here for a full PDF version of the advisory.
The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson, P.C., is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson, P.C. be liable for any direct, indirect, or consequential damages resulting from the use of this material.
