Medicare's statistic doesn't tell whole story of insufficient documentation

LETTER — Posted Jan. 31, 2005

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Regarding "Medicare zeroes in on E&M coding as key source of payment mistakes" (Article, Jan. 3/10):

The highlighted box shows "Failure to back up claims with sufficient documentation" as the largest problem, responsible for 43.7% of errors. Not providing sufficient documentation does not mean that the claim was unjustifiable. In fact, in our experience, even providing all requested documentation may not save you from being labeled as having failed to comply.

In 2002, certain claims in our specialty were under review, and we received an unusually high number of information requests. We received these requests after filing the claims; we were not given prior instruction to submit concurrent information with any claims.

These requests were crafted as form letters, easy to send but very burdensome and time-consuming for our staff to comply with, because of the volume of information that could be requested by the mere act of checking boxes like "Document all medications and surgeries" for very sick hospitalized patients with 6-inch thick charts. Nevertheless, our staff researched patient charts, copied pages and sent them to the designated reviewers.

In many cases, the response was simply the same letter again, as if we had never sent anything.

My office manager was tearing her hair out. We called the medical director, who checked with the nurse reviewers. They agreed that we had sent them so much stuff that we had overwhelmed their resources with our response.

We asked them to please communicate with us as to exactly what they were trying to determine, and maybe we could just give them a straight answer to a straight question.

The next thing we heard was that they decided that they should have just paid the claims in the first place, so they did.

But Medicare wasn't done with us yet. In 2003, we received a letter from the regional office notifying us that our claims of the previous year had been audited, and as a result we were on record for failing to provide adequate documentation for our services!

Stunned, I called the provider relations representative for the region and objected.

I told her that we had provided all documentation that had been requested, which she could verify by talking to the nurse reviewers in our area. I told her that providing all the documentation requested was very time-consuming and burdensome for my staff, so we were not likely to forget it.

I was floored at her response. Sternly, she told me that it didn't matter that we had sent all the requested information. Since we did not send the information with the original claims -- before it was requested! -- we were considered to have not provided it at all, at any time. Furthermore, nothing could change that formal determination regarding our claim history.

So, that is my perspective of the convenient manner in which Medicare stacks the numbers to make it appear that physicians are noncompliant.

E. A. Smith, MD, Baton Rouge, La.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2005/01/31/edlt0131.htm.

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