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Last Modified: 9/26/2017 Location: FL, PR, USVI Business: Part A


“This was once viewed as a problem for just the billing office. Now we see it (claim documentation) requires a clinical component in reviews and appeals. It is a much greater collaborative effort.”

-Cheryl MacKinnon
Director of Government Insurance
Lee Memorial Health System

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Providers take proactive approach to improving medical documentation

Using data and analysis from First Coast Services Options Inc., (First Coast) Florida hospitals are working to improve their medical documentation of services they provide Medicare beneficiaries to ensure those services are paid in full.
First Coast recently presented analysis showing hospitals in Florida may be short-changing themselves by as much as $360 million in potential lost reimbursements, because the medical documentation filed with each claim falls short of Medicare standards for demonstrating medical necessity for hospital services.
In 2012, First Coast found 9,100 denied Medicare claims lacked the necessary medical documentation in order to be paid. Since First Coast presented its concern to hospitals through webcasts, many hospitals have begun taking action to improve medical documentation in their facilities with the goal to reduce the number of denied claims.
Cheryl MacKinnon, Director of Government Insurance for Lee Memorial Health System (LMHS), said First Coast webinars were important to their efforts in improving the health system’s experience with documentation of physician orders and patient history.
After reviewing the initial educational materials from First Coast, LMHS began tracking additional document requests (ADR) and requests for more information about individual claims from the recovery auditor. Their strategy evolved quickly to employing two staff members to develop and manage a revised process for tracking such requests on a daily basis.
Sixteen months into the process, the ADR and recovery auditor tracking system produces monthly reports that LMHS uses to improve medical documentation. “We can tell when (requests for documentation for) one DRG is going up or going down and be proactive about improving our process,” MacKinnon said.
Second, LMHS placed two nurses in their surgical scheduling area to review patient charts in advance of surgery to ensure the chart clearly demonstrated the medical necessity of the scheduled procedure. MacKinnon said this was a critical component to improving their experience with prepayment review of medical claims. “This was once viewed as a problem for the billing office. Now we see it requires a clinical component in reviews and appeals. It is a much greater collaborative effort,” she said.
MacKinnon cited DRG 470, major joint replacement, as an example of how LMHS changed its approach to medical documentation. She said the data suggested the system was on a prepayment review.
“We worked with our orthopedic physicians and surgical teams to focus on improving documentation. By working collaboratively, it helped us see the whole picture. Now the physicians and their offices know well before the service is provided what we need in order to get a claim paid,” MacKinnon said. MacKinnon says the system is no longer seeing the level of ADR and recovery auditor requests they were experiencing prior to January 2012.
“In the beginning it was a baby-step process with a few of our targeted DRGs. Once we began, it became a self-improving process as our physicians and their staffs learned what to expect for all procedures, not just those DRGs we were focused on,” MacKinnon said.
Though the analysis showed a clear majority of the denials fell short due to incomplete documentation of medical necessity, First Coast also denied hospital claims for inappropriate levels of care such as an inpatient admission for an ear infection and a series of other reasons such as incorrect diagnosis codes applied to procedures.
First Coast maintains recorded webcasts that summarize the issue for health providers and may be reviewed on First Coast’s provider education web pages.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.