How to Respond to an Initial Request for Records, Medicare & Medicaid Audits

Hoyt Torras
December 3, 2012 — 1,121 views  
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One of the biggest mistakes a medical practice can make when they receive a request for medical records from a payer, such as Medicare or Medicaid, is to quickly copy some records and throw them into an envelope. Most audits start with the payer, or their audit contractor, providing a list of names and dates of service for which they are requesting copies of medical records.

Here are a Baker's Dozen worth of tips for those type audits:

  1. Before submitting records to the payer or their audit contractor, make sure records are legible and that there are records for each date of service. Further, make sure the documents are well-organized so that auditors can easily find the pertinent records.
  2. Designate one person to be responsible for responding to the audit and follow-up.
  3. Allow plenty of time to respond. Pay close attention to the deadline for responding in the audit notice. Sometimes you may be granted an extension. Request an extension early, and request it in writing.
  4. Read the audit request letter carefully. It usually lists the types of information the auditor expects. Don't worry if the generic list you're provided includes information that is not applicable to your patient or the services provided.  Just make sure you send a copy of documentation in your records that supports each service billed.
  5. Send only copies of the record, not the original, and number the pages.
  6. Make at least one copy of the records you submit, exactly as submitted. It is more difficult to appeal an audit when you and your advisors are not sure what was sent to the auditors and used to render their initial decision.
  7. Make sure to submit documentation for each date of service requested, but do not fabricate documentation if you do not have it.
  8. If your office note for an Evaluation and Management  (E/M) code refers to a prior history, you should include documentation related to those aspects. This is especially important for new patient visits where all three elements, History, Exam and Complexity of Medical Decision Making, will be reviewed.
  9. If lab tests, x-rays or other diagnostic tests were ordered and billed by your medical practice for the date of service, make sure the report is in the record submission even if the report was not available for several days, after the encounter. Even if the tests were performed or billed by another physician or entity, include them because they may help justify higher levels of E & M services.

10. If you performed a consult, even if it is a payer such as Medicare that no longer recognizes consult codes, include a copy of the report to the referring physician. Again, that helps indicate the extent of work performed on the date of service.

  1. If your handwriting is not legible, it may be best to have the records transcribed. Some auditors may deny a service if the records are not easy to read. At other times, auditors may miss important aspects and down code or deny the service. If you transcribe old records, make sure it is clear that the transcription is recent, with the current date prominently displayed. When you submit the record, place the handwritten copy behind the transcription. Usually, you should include a comment about the recently transcribed records in the cover letter you send with the audit submission.
  2. Write a cover letter outlining the contents of the package. Provide the name of a contact person at your medical practice along with phone and email address in case the auditor needs additional information.
  3. Use FedEx, UPS or mail with return receipt requested so that you have a record of delivery. Some payers allow electronic transfer of records.

Finally, the steps you take to comply with the request will make a difference in how the audit proceeds and how much time and effort it takes to appeal any adverse findings.

Hoyt Torras