The following is a guest post from Dawn Crump, Vice President of Audit Management Solutions at HealthPort
Medicare Administrative Contractors (MACs) audit hospitals claims. They compare Part A and Part B claims and look for discrepancies. While these reviews have historically been performed post-discharge, the MACs also conduct pre-payment reviews. MACs ask for documentation to support claims—and hospitals are obliged to provide it. This is nothing new.
What is new is the detail of proof they are requesting. MACs are seeking deeper documentation than ever before. A typical request from the MACs might include language as follows: “We need any and all information to substantiate this treatment.” In many cases, this depth of information only resides within the physician office records.
MACs Seek More Detail
Many hospitals are continuing to respond to MAC requests as they always have—by submitting the appropriate portions of the hospital medical record. Typically, approvals have been granted. But there is smoke on the horizon.
Hospitals have reported receiving denials when they fail to submit physician office records that further substantiate every preventative and therapeutic effort taken prior to more aggressive, in-hospital care (e.g. surgery). And now word on the street is that the RACs are moving toward seeking similar levels of validation for certain medical procedures.
In the immortal words of Bob Dylan, “The times, they are a changin’.” There is no sense in denying the inevitability of deeper MAC (and ultimately RAC) requests. I can summarize my advice in two small words: Be proactive.
Six Steps to Prepare for the Inevitable
Follow these steps to begin incorporating physician office records into your MAC, RAC and other auditor responses. In doing so, you may mitigate the risk of more probing audit requests and prevent revenue take-backs.
- § Start now in providing the full extent of what the MACs may soon expect—detailed physician office records that substantiate cause and what preemptive treatment was provided.
- § Endeavor to create a process that proactively satisfies these new-style MAC requests. Train your team to include appropriate physician office records in submittal packets. Assume that the RACs will soon seek similar documentation.
- Meet with your physician groups and their practice administrators as a matter of course to discuss issues, obtain consent and agreement to obtain their records for this purpose.
- Gather all documents that demonstrate a history of prior conservative medical treatment; showing any time the patient had preventative therapy and indicating surgery was the last resort.
- Develop internal documentation protocols and guidelines for high risk MAC procedures.
- Once a MAC request is received, via email, paper, fax or hand-delivery, scan it in and merge it with hospital records.
Though these efforts are above and beyond what has been customary to this point, they’ll prepare you to satisfy the next generation of audit request, both from MACs and potentially RACs. And isn’t it always best to change with the times?
Dawn Crump is Vice President of Audit Management Solutions at HealthPort. She formerly served as Network Director of Audit and Compliance at a large regional healthcare system in Missouri.
