Handling a Records Request Like a Pro
Kathy Mills Chang
MCS-P, CCPC, CCCA
Another envelope arrives from yet another insurance company, among the many you will receive today. The envelope is thin and you can tell there is likely no check inside. What do you do? For certain, you don’t give it top priority. It shouldn’t get the same type of attention that you give to an envelope that clearly contains money. You set it aside thinking there will be more time later to deal with something that is likely just a nuisance.
You make it back from lunch a few minutes before your first afternoon patients arrive and you open the meager envelope. As you correctly guessed, there is no check. Bummer! What was there, however, can be just as important as money, and perhaps even more so. It is a records request.
Records requests are a fact of life in every healthcare practice today. How your practice responds to these requests is a representation of you and your practice’s reputation. They can also affect whether or not your doctor gets paid. Your responses to these requests reflect your professionalism and attention to detail, so it’s important that they are handled promptly and accurately.
"Any alteration to a medical record by adding or omitting information could be deemed fraud.”
When you receive a records request, the worst thing you can do is put it aside and forget about it. In a recent report from Palmetto GBA, Railroad Medicare, for the period ending June 30, 2017, the number one reason for errors was that no records were provided. The second most common reason was insufficient documentation. This is not to say that the documentation was missing, but rather it didn’t meet the minimum requirements. The patient’s records are that vital proof. It is your responsibility to respond to the request in order to prove the service was actually provided and that the billing wasn’t fraudulent.
So, you’ve hauled out that records request you set aside, what now? The easiest way to provide exactly what is required for a thorough response is to use a checklist template. In fact, Palmetto
GBA provides one for offices to use as they prepare the records for review. Having a templated checklist readily available so that you can more easily gather and organize all that is requested will allow you to respond quickly and efficiently. Such a template makes responding to a records request an easy task—it can also showcase your professionalism. If you let the template lead the process, the result will be a well-told story of what occurred with a patient during treatment and that provides a verbal illustration of the case management involved. The completed template becomes the cover page for the patient’s chart, so when you respond to the records request, the reviewer that receives it can see all the critical information at a glance. Showing that you are responsive, organized, and complete will go a long way to allowing the reviewer to analyze your records easily and will generally end with a favorable result: getting paid!
Getting it right the first time should be your number one goal. That means checking all your facts and data and creating documents that are legible and complete. If your doctor’s records are hard to read, it may be worth the small investment in time to transcribe and translate them. Change abbreviations into full text and transcribe the written notes into a narrative format, but be sure not to change the context. Send both the original and transcribed copies in for review. Make sure there is sufficient data to support medical necessity and that the documents are in chronological and supportive order so as to explain treatment as it occurred. This is the time to let your organizational skills shine. If you don’t have any organizational skills, call in reinforcements in the persona of the doctor or another trusted, organized staff member.
Before any documentation leaves the office, it is critical that you ensure the doctor has completely reviewed the information before sending it. The doctor is ultimately the one responsible for the response, and this is your last chance to make sure that amendments and clarifications are in order before the response is sent to the requester.
And what if you realize later that you made a mistake? First of all, don’t try to change what has already documented. Don’t add anything to the records and do not omit anything from existing records. Any alteration to a medical record by adding or omitting information could be deemed fraud. Don’t fool yourself into thinking that something as insignificant as changing the date of
service to match the bill or adding a pain scale or other data that was not part of the original record is acceptable. Corrections and additions can be made to clarify the original record, but they are submitted as separate documents with a full explanation of where the corrections, additions, or commentary need to be and the rationale behind the changes/additions.
Once that is done, include any additional supportive documents such as: X-ray Reports, a signature log (if applicable), the attestation of records, an abbreviation key, page numbers, and copies of any relevant policies. That should do it. Follow these simple directions for a document that you can be proud of and that your recipient will appreciate.
Mills Chang is a certified medical compliance specialist (MCS-P), a certified chiropractic Professl°nal coder (CCPC), and certified clinical chiropractic assistant fCCCAJ. Since 1983, she has provided chiropractors with reimbursement and compliance training, advice, and tools to increase revenue and reduce risk, Kathy leads a team of 30 at KMC University and is considered one of our profession ⅛ foremost experts on Medicare documentation and compliance. She or any of her team members can be reached at 855-832-6562 or [email protected].
