Medical practices receive many communications from payers that aren’t indicative of a problem. A payer needs more information to process a claim. Or, a Medicare Advantage plan wants to look at records to capture all diagnosis codes on its members. If you missed the CERT webinar in April, take a look at the types of government records request you might see, by downloading the handouts for that webinar.
A pre-payment additional documentation request (ADR) is not an audit, but if the documentation you submit does not meet the requirements for the codes, it is a warning to the practice to improve the documentation and/or change the coding for the service. And, sometimes, the payer is auditing claims based on unusual utilization or a complaint.
Responding to a payer audit
A request for the records for multiple encounters should get a practice’s immediate attention. The audit may come from a government payer or a private payer or from a contractor working for a private payer. Don’t ignore the request for records. If the payer is requesting 40-50 notes, consider contacting your health care attorney before you respond, and be careful not to miss deadlines.
Login to read the rest of this article
Don’t have a login? Become a member, or learn more about the benefits of membership by clicking on the link below.