Medical Record Review Preparation


The Medicare Integrity Program is responsible for paying claims correctly and reduce the claims payment error rate as defined under the Government Performance and Results Act (GPRA). In order to meet that goal, Contractors must ensure that they pay the right amount for covered, medically necessary, and correctly coded services rendered to eligible beneficiaries by legitimate providers. In recent years CMS has launched an expanded effort, reviewing a significant volume of Medicare claims, to learn more precisely where errors are being made.

When peeling back the layers of the reimbursement onion, attention is turned to the Electronic medical record (EMR). EMRs have now penetrated the SNF marketplace.  Now more than ever, medical records are in a hybrid state as SNF providers move towards a true electronic medical record (EMR). Currently, there is not a single product for the SNF setting that can interface with all modules of a medical record, from pharmacy, SNF billing, MDS, nursing documentation, rehabilitation documentation, physician orders and notes to name a few.  It is not unusual to find that the facility’s records are housed in multiple places including an almost archaic paper record. The EMR, is likely dispersed across two or more electronic storage systems.

  • Searching electronic medical record component parts in an effort to provide great care to the residents poses a unique challenge for the nursing facility. 
  • Couple that with the national roll-out of Medicare’s Audit programs, and there is a recipe for extreme reduction in revenue stream for the nursing home.
  • Medicare Auditors perform multiple types of reviews to find improper 
  • Medicare payments to the nursing facility. These reviews can be both automated reviews and/or on site in-person reviews.

A flurry of questions must be addressed before a medical record can be submitted for review  and/or appeal. 

Potential Risk to Providers:

Collecting medical record information from various locations, and getting a complete medical record out the door within the required number of days of the request letter becomes a challenge. One missing record has the potential to cause millions in unnecessary denials and lengthy appeals.

Once a Contractor has identified a provider required to pay back monies billed for Medicare claims, the hunt continues exposing the provider to on-going reviews.

  • The risk of extended governmental medical reviews is placement into a focused review program of all claims billed by the provider to Medicare. 
  • Worse, is the ability of the Contractor to use statistical sampling to extrapolate  and calculate the amount of overpayment made by Medicare to the SNF provider.

Harmony assist providers in review and preparation of medical records under governmental Medicare Medical Record Review. 

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