By Laura Loeb, Esq.Hogan & Hartson LLPOutside Counsel to IDSA
A request for medical records by a payer needs to be taken very seriously. Your office staff should be informed that if such a letter is received it should be brought to your attention immediately. You should read the letter carefully, noting when the records are due. Sometimes, but not always, the letter will state the nature of the audit—for example, that you were found to have a high frequency of billing 99254 and 99255. The payer has an obligation to provide the physician with the name and identification number of the patient records and the dates of service in question. A request for records on Jane Smith without providing you with the dates in question is not sufficient.
I recommend contacting the person who sent the letter immediately. First, attempt to determine why you received the audit letter. For example, if you received the letter because you were an outlier with your billing pattern, ask against what type of physician you were benchmarked. Often infectious diseases physicians are benchmarked against general internists. So, of course, your billing pattern would look unusual under that comparison.
You should be identified in the payer's records as an infectious diseases physician by specialty identifier code 44. Ask to make sure you are identified as a subspecialist. Also ask whether the benchmarked billing pattern is of rural or urban physicians, physicians from the same part of the country as you, and whether they are office- or hospital-based. You are entitled to know this information. Ask to speak to a supervisor if you are not provided this information.
No matter what the answers, however, you will still have to comply with the audit request for records. Do not let these inquiries delay your search for the records. You will probably need to ask for an extension of the audit letter's deadline in any event. It is critical to locate all the records in question, so additional time is usually necessary. Generally speaking, the payer will extend your deadline, but this is not always true. Locating the records may be particularly time-consuming if some records are for inpatient services where the hospital has the documentation. If that is the case, you should let the payer know why you need the extension. Get the extension in writing or at least confirm in writing yourself with a letter to the payer that, based on your conversation of X date, the payer extended the deadline to Y date.
You should also ask the payer what type of health care practitioner will be auditing your records: A nurse? A doctor? If a doctor, what kind of doctor? You can try to request that an infectious diseases physician audit your records, but chances are the payer doesn’t have an infectious diseases physician on contract to do this audit work. If your practice extensively involves a certain type of patient, you should request at least that the reviewer have some clinical background in this area.
Once you have assembled the requested documentation, you should review the files, make copies and send in the copies. In reviewing the documentation, you may determine that there are ways you could improve your future documentation. Make those changes. Do not wait for the audit results if you feel you have areas where you could improve. On the other hand, I do not recommend acknowledging in your submission to the carrier that the documentation in these submitted records is lacking and making offers of settlement even before the payer has audited your records.
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