Mitigating claims risk in medical necessity

There are numerous reasons for claims denials but most of them come down to some form of documentation error, according to Karen Meador, MD, MBA, Senior Physician Executive and Managing Director at the BDO Center for Healthcare Excellence in New York, NY.

Furthermore, most of the claims she has seen that “rise to the level of dispute” have some sort of issue around medical necessity, she says.

Medical necessity, as defined by the American Medical Association (AMA), refers to healthcare services or products provided to a patient “for the purpose of preventing, diagnosing or treating an illness, injury, disease, or its symptoms.” This is in keeping with generally accepted standards of medical practice, that are clinically appropriate, and “not primarily for the economic benefit of the health plans and purchasers.”
 

Get specific

One of the common problems contributing to poor documentation, Meador says, is a byproduct of EHRs. In a bid to save time, certain functions, such as copy and paste features and generic templates, can lead to a lack of specificity as physicians copy notes into claims.

“Notes can look very similar not only one day to the next for the same patient, but often among different patients,” Meador says.

She says physicians must take care to make sure that each note is “specific and unique to that patient” even when using templates.

“Physicians should routinely ask themselves ‘have I put uniquely identifying information regarding this patient, regarding his or her history, review of systems, exams, and the plan?’” she says.

In addition, the check-one-box function of many templates isn’t always enough to make the case for medical necessity; more complex notes are often required. “I can often review medical records and see that based on the vital signs, certain labs and the overall exam, this patient needed to be admitted, but the physician wrote a very brief plan, often following a template,” Meador says.
 

Don’t forget the signature

Another byproduct of EHR systems is that they allow for a physician to make an electronic signature instead of a physical signature. However, Meador says, some statements include language that says “signature not required.” An unsigned claim will cause a rejection from the payer.

In newer EHRs, “that language has since been changed to instead say ‘electronic signature,’” she points out. But not all EHRs are up to date.

The timeliness of a physician’s signature is also important, she says. “We do still see problems where the signature happens too long after the note was entered.” She says that can be problematic if a nurse practitioner or other mid-level practitioner wrote the note and then the physician signed it later.

“If that’s not done timely, that can be a potential opportunity for the payer to challenge,” she says.

Obtain oversight

To save a physician hassles in claims denials and appeals around medical necessity, Meador recommends they involve a third-party, either to do the coding, or to double check a physician’s coding.

Having a third party check the information that supports the documentation can avoid what Meador calls a common pitfall, which is where the physician, crunched for time, relies upon information in their mind from the physical exam and visit rather than confirming that it matches what was documented.

Having a coding expert or a coding team on board can also provide feedback to ensure that the code was appropriate for what was documented, she says. Such feedback might help physicians code appropriately to a higher level, as well.

She recommends physicians hire an outside group to come in annually and do a preventative audit of the records. “It can be very helpful pulling a random selection of records for each of the physicians and then getting an assessment of the accuracy of the coding, billing and thoroughness of the documentation.”

Oversight can only improve billing for medical necessity. “Physicians need to be reminded that one really has to think about how one communicates with the payer,” Meador says.