How to Handle Medical Reviews
The Office of Inspector General (OIG), oversees Medicare compliance and has increased the number of medical reviews. High overpayment rates during audits has prompted them to do so.
To avoid payment denials and flagging of the SNF for a focused medical review, you must have a plan in place to handle the request. You must act quickly, as some FIs (Fiscal Intermediaries) have started to deny claims when the requested medical records were not received within 45 days. The count startes from the date on the FI letter. This could mean that you have lost 4 days before the letter even reaches you. Holidays do count, as do any day on the calendar.
Consider the following plan:
- Have some one oversee the process
- Set your turn around time between 72 hours to 1 week (latest would be midnight of the 45th day)
- Pull only records and data requested during the dates of service they are requesting (not asked for/do not give)
- Have clinical staff review the documents to make sure there are notes to support therapy or covered services
- Send all that is requested
- Make a copy for the facility of all that is sent and save in case of additional requests or problems
- Send the data by certified mail return receipt requested
- Log all requests and outcomes
- Look for trends in requests. Investigate to ensure compliance.
Remember that a medical review occurs randomly. It is only a matter of time before your number comes up.
Ecumen Consulting can help you prepare, audit, educate and put systems in place.