With the insurance payers requesting medical records at an alarming rate, it is critical that the client chart complies with multiple levels of requirements. Most centers are now serving three masters: State Regulations, Accreditation Requirements and Payer’s inconsistent criteria. Facilities’ and Center’s Policies and Procedures should include routine chart audits conducted by a compliance officer, peer reviewers and even third-party consultants. It’s that IMPORTANT! Claim reimbursement is often contingent on a payer reviewing the chart to determine if it meets medical necessity.
Comprehensive clinical documentation is key to increased lengths of stay, insurance reimbursements and keeps your facility protected should a payer request records for audit. Medical necessity can and does vary by payer. As the payers become increasingly demanding, your best line of defense is keeping your chart SMART. Clinical and Medical notes must be concise, descriptive, speak to the client’s treatment plan and tell the story of why the client is in need of your care.
Some of the most common oversights that often result in a non-payment or recoupment are:
- charting in the wrong level of care – If your client is in IOP, the note must stay IOP
- notes cloned in clients charts
- lack of detail to the acuity of the client’s presenting condition
- treatment plans not reflecting individualized objectives
- lack of family involvement or rationale for non-family involvement…. just to name a few.
You must make sure that your client’s presentation in the chart is congruent to the presentation in person. Consistently document what the barriers are to the client’s discharge. A good question to ask yourself, clinician or clinical team is “Why if this person left today would they be at immediate risk for decompensation”?
It’s important to make a best practice of evaluating the insurance payer guidelines on a regular basis as they change frequently and without notice. Integrity Billing’s practice includes evaluating the charts for medical necessity as well as consulting with our clients on the most effective, efficient manner to document client care. This allows the clinician’s to focus to remain on healing the clients.
For more information on how Integrity Billing can help you keep your chart SMART, call us at 800.683.5640