Your clinic can get an A on its next chart review

Managing the reviewer is a big factor in passing

(Editor’s note: This is the first of a two-part series on preparing for a medical record review. In this issue, Outpatient Reimbursement Management outlines steps you can take prior to a site visit from your commercial insurer. Next month, we’ll discuss your role during the review itself and how to deal with your facility’s final score.)

When a payer comes calling, asking to be led to your clinic’s chart room, that isn’t the time to start worrying about the condition of your patient files, say veterans of medical record reviews. (For a list of sources of information about medical record standards, see p. 28.)

Unfortunately, facility managers become unduly frazzled by the pending event. They should worry more about the condition of their files long before the insurer comes knocking.

That’s the opinion of outpatient administrators who have been through the process. "If you’ve maintained high standards throughout the year, you should have nothing to worry about," says Raymond E. Grundman, RN, MBA, MSN, general manager of SurgiCenter of Greater Milwaukee.

Grundman, who has been under a health plan’s microscope before, says it’s understandable for management at many freestanding facilities to feel intimidated by something that may be new. Based on his experience, however, reviews are usually a positive, constructive affair.

In most cases, even with Medicare surveys, neither the reviewer nor the facility’s management wants to be hostile, Grundman says. Both are eager to avoid the worst-case scenario — the review goes so poorly, the health maintenance organization (HMO) terminates your provider contract.

Getting terminated will upset your patients, who also happen to be the HMO’s enrollees. Neither side wants that, says Susan Keane Baker, MHA, principal at Malpractice Prevention Seminars in New Canaan, CT. The company gives seminars on medical documentation.

For you, there’s also the matter of having to answer to management at your host hospital or health system if you are owned by one.

Facilities rarely fail

In actuality, most facilities don’t fail reviews. They end up being helpful learning experiences, Baker says. But they do require preparation. Here are some suggestions:

Anticipate what the reviewer will look for.

HMOs differ widely on what they consider important, says Baker. At North Denver Surgery Center in Thornton, CO, reviewers look for medication and immunization notes. They also inspect for loose or dog-eared forms, says Charlotte Y. Santoro, RN, the center’s director.

Coordination of patient care, evidence of medical necessity, a treatment plan, good coding, and informed consent also are big factors, experts say.

The simplest way to anticipate what is important to a reviewer is to call the insurer. Ask for a checklist, Baker says. Some carriers will refuse, but discuss the visit and determine what will be asked for, says Grundman. "Their criteria should not be a secret," says Baker.

Create a physical environment that helps you control the actual review.

Set aside a private space for the inspection away from patient areas. Unless the reviewer insists, don’t permit the review to occur in the chart room where the individual has access to all the files, Baker advises. If the reviewer insists, explain truthfully that you are concerned about his or her access to other files, says Baker.

Give the reviewer only files that are requested, and don’t allow the chart inspection to turn into a tour of the clinic or a claims audit, Grundman warns. You can halt the review if it turns out that the reviewer is actually there to audit your billing in order to challenge past payments, he adds.

Research some legal issues.

Check with your local health information management group regarding the legalities of preparing the actual patient file for inspection. In most states, it is unlawful to remove or permanently alter documents in a chart, says Baker. If you recopy a soiled or torn document, make sure you place the original in a sealed envelope in the file, she adds.

In most cases, obtaining patient consent for the chart review won’t be necessary. Insurers normally obtain consent when the enrollee signs with the plan. But confirm that with the carrier, says Grundman.

Determine ahead of time what you cannot control.

There will be aspects of the review that you will not be able to control, including the review’s duration. Plan for it to take the maximum amount of time, Santoro says.

A reviewer may ask for specific charts by either patients’ names or diagnoses. (In most states, reviewers are only permitted to inspect charts belonging to their own HMO’s enrollees.) Those charts you can pull and prepare before the actual reviewer.

Brief your office staff

Also, you may want to brief your office staff. The reviewer may want to interview them on matters of registration, scheduling, or patient relations. The more prepared you are, the more organized your facility will appear, Baker says.

Above all, if the reviewer happens to be rude or uncooperative, you can always end the visit. Call the insurer and request another reviewer, Grundman says. "There has to be a sense of trust and partnership in this process," he adds.