Wiki Appealing with lacking documentation

[tbragg36]

Here's some background. The provider is very new to the insurance world. They started their practice in 2020. I've been with my provider for 2 yrs now. Throughout that time, I have stressed documentation requirements. If our notes/encounters are requested, it could be very unpleasant. BSCA asked for documentation on all BSCA members we treat. I was not surprised by the outcome of the audit. BSCA is requesting a very sizable refund. From my experience, usually, the provider wants to hear why the carrier themselves made this decision. I called and spoke with BSCA about what was lacking in the notes/encounters. BSCA said our documentation was very vague; there were no specifics, and questions and concerns were discussed with the patient, but nothing on what was discussed with the patient. We are lucky BSCA didn't say anything about cloning. To me, that was very apparent. Now he wants to appeal this decision. So here I am, trying to figure out how to combat what to say in the appeal letter. He's looking at the dollar signs they are requesting back. He says it will take BSCA too much time and workforce and let it slide. I've written appeals before. However, this situation is new to me. I'm stumped on how to write an appeal letter showing treatment was medically necessary when documentation is incomplete. I could use some ideas.

 

[thomas7331]

That's a tough spot to be in and this could be a lot of work depending on the volume of claims that's involved. You can't really appeal an entire refund request that involves multiple records - that would be somewhat fruitless. What I would do to start is to set aside the question of medical necessity, and to just focus on this from a coding standpoint. Look at each individual refund request and compare it against the documentation for that visit and ask yourself if BSCA is correct in their assessment, based on coding guidelines, or whether the note really supports what was originally billed and should be appealed. Separate these out into the two groups. For the ones where you think payer is correct, you just need to explain to your provider that you don't have documentation to support an appeal based on coding and you need to accept those determinations and consider it a learning experience and a cost of doing business. For the refunds you disagree with and think you can challenge, create an appeal letter template and customize it for each encounter, with a paragraph explaining why the documentation supports the level billed. Each appeal letter should be attached to the supporting documentation for that claim. I would probably summarize all this so that you have a record of what's going on and can track the progress, and that you can share with the provider, which will hopefully help them understand the consequences of poor documentation and the need to have robust support for the codes they are billing.

Medical necessity is a more difficult issue and if they are challenging the level based on that rather than on the key coding elements, this is going to be more difficult and it's something you'll probably need your provider's help with. You might consider attaching some of the clinical examples from the appendix of CPC to show that it is reasonable for certain patient conditions to receive a certain level of an E/M service, but ultimately, it's not really within the scope of a coder's training to understand or make arguments about medical necessity, and your provider should help you compose appeals explaining why a particular patient's symptoms or condition warrant a particular level of E/M. The provider may want to consider contacting and working with the payer's medical director if this is the case here because a medical necessity issue really requires a peer-to-peer discussion and isn't something for a coder to be taking the lead on.

I hope perhaps this may help some, good luck with this challenge.

 

[Orthocoderpgu]

This may be too late, but Thomas gave you some great advice. You said that you were stumped on how to write an appeal letter when the documentation is incomplete. Don't waste your time. If the documentation truly does not support the code/s submitted appealing them is not going to get them paid. It will be a waste of time. I agree with Thomas, if you have the resources and ability separate the encounters where you feel the documentation does support the code/s, focus on those. At the very least this should be a teaching experience for providers. Quality documentation matters.

 

[tbragg36]

This may be too late, but Thomas gave you some great advice. You said that you were stumped on how to write an appeal letter when the documentation is incomplete. Don't waste your time. If the documentation truly does not support the code/s submitted appealing them is not going to get them paid. It will be a waste of time. I agree with Thomas, if you have the resources and ability separate the encounters where you feel the documentation does support the code/s, focus on those. At the very least this should be a teaching experience for providers. Quality documentation matters.

Thank you for your input. Thomas did have a great suggestion, and I did as he suggested. Separating the codes was easy since we only have four codes.
Instead of separating the codes for an appeal, I separated the codes to be able to write a response to my provider. I explained to him that I looked at our codes separately, looked at the documentation, and tried to combine two of our codes together. Still no supporting documentation for these codes. I explained that we could appeal the E/M code, but it was up-coded, and BSCA would still want a partial refund for that code. He was confused and said he didn’t know what BSCA wanted. I explained that all of our encounters said, ‘patient tolerated treatment.’ BSCA was looking for patient-specific documentation. They wanted to know what equipment was used, what techniques were implemented, and how the patient tolerated the treatment. I sent my provider a copy of a colonoscopy note I had. The colonoscopy note said what techniques were used, what equipment, and how it was advanced through the colon. I was hoping my provider would get a clearer understanding of patient specifics. I received a response from him saying, ‘So am I to just give away my trade secrets?’ I said, ‘no, but BSCA will continue asking for their money back.’

To bring you up-to-date, my provider is now writing addendums to all the notes we faxed to BSCA. I pointed out that BSCA’s ongoing correspondence says, ‘any additional documentation will not be accepted.’ He says BSCA has to take these addendums.

During this process with BSCA, Medicare requested 21 encounter notes to review. The contracted auditor sent letters to our patients asking all kinds of questions. The letter said something about fraudulent billing. Some patients got scared and stopped treatment. The CEO of the company wrote a nasty complaint letter to our MAC. I’ve reached out a few times to the contracted auditor, and they will be taking their finding to CMS on 3/15/23. CMS will decide that day if the case will be closed or if CMS will be requesting additional records. I think they will be pulling a lot more of our notes. And yes, I've been looking for new employment.

 

[kdlberg]

That's kind of odd that the MAC sent letters about "fraudulent billing." I would think that since things are still under investigation, they would have erred with something like "potential billing issues." Fraud has a very specific definition. They're ascribing an intent that may or may not be there. IMO, I don't think your employer is trying to defraud anyone--I think they're just lazy with the documentation. They haven't done their due diligence to familiarize themselves with the requirements; "I didn't know" doesn't fly with RAC. They'll say "It's published it, you should have known."