First Coast Service Options Inc. (FCSO) has received questions from physicians regarding medical record review or, more specifically, requests from Medicare for medical records. A statement in both local and national coverage determinations (LCDs and NCDs) notes that medical record documentation maintained by the performing physician or allied provider must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be maintained in the patient’s medical record. This information is normally found in the history and physical, examination notes, office/progress notes, hospital notes, and/or procedure report.

Medical record reviews are conducted by different entities contracted by the Centers for Medicare & Medicaid Services (CMS) and other government offices, and each has distinct program goals. Under the Medicare Integrity Program enacted by Congress, entities such as FCSO, a Medicare administrative contractor (MAC - pays Parts A and B provider claims) are distinct from a program safeguards contractor (PSC). As a general rule, a PSC is accountable for reducing fraud and abuse in the Medicare program; a MAC is responsible for reducing the Medicare fee-for-service claim payment error rate by paying claims appropriately and accurately. There may be some overlap in responsibilities and programs among contractors.

Other Medicare contractors that pay claims and may request records for medical review include the durable medical equipment regional carrier (DMERC) or DME MAC (DME Medicare administrative contractor) and the regional home health and hospice intermediary (RHHI). Two special PSC contractors administer the Comprehensive Error Rate Testing (CERT) program, and systematically request records for medical review.

The Recovery Audit Contractor program will be implemented nationally by 2010, and the selected contractors will be responsible for conducting claims reviews in order to determine inappropriate over- and under-payments. On October 6, 2008, CMS announced the names of the new national RACs (Recovery Audit Contractors). The new RAC for Florida is Connolly Consulting Associates, Inc. of Wilton, Connecticut, and they could generate medical record requests, as well.
(Note -- implementation of this program is currently suspended pending a review by congress of recent protests.)

In addition, the Office of the Inspector General (OIG), in the Department of Health & Human Services (which governs the Medicare program), conducts surveys or assessments that involve the claim payment process and necessitates medical review. Medical records for these reviews, and subsequent follow-up reviews, are requested by the entity contracted by the OIG for this purpose.

The following is a brief outline of medical record review: note that each program has a limited impact on the number of providers and/or number of claims reviewed.

Medical review of initial claims -- the MAC requests records in the prepayment development of a claim.

Claims may have been submitted with procedure code(s) that require additional information for coverage and/or payment (e.g., an unlisted code).

One of the services on the claim is under formal review based on utilization or other audits (these are usually outlined in a national or local policy or may be a PSC request).

Progressive correction action (PCA) process medical review -- the MAC process to lower the claims payment error rate. This is data-driven with a provider education and/or policy development focus.

Post payment request for the documentation of claims.

In some instances, may include prepayment development of a claim for certain codes submitted by a provider.

CERT program -- The CERT documentation contractor requests records for review by the CERT review contractor. The CERT program randomly samples 200 claims per month per contractor nationally.

Post payment request for the documentation of claims, usually from the prior year.

PSC and OIG -- Programs to prevent fraud and abuse.

Post payment request for the documentation of claims.

Prepayment medical review related to a program safeguards initiatives -- requests come from the MAC (such as FCSO) since these are new claims, although the documentation will be reviewed by the PSC.

FCSO paid over 90 million claims in fiscal year 2007 for Part A and B providers in Florida and Connecticut. Fortunately, only a small percentage of these claims required submission of medical records for review. If you receive a request for medical records on a Medicare beneficiary and are unsure of your responsibilities, please contact the Medicare provider call center at 1-888-664-4112 (Part A) or 1-866-454-9007 (Part B) for clarification, or call the number on the requesting letter for more details. Your prompt response to a legitimate request will benefit you, the beneficiary, and the Medicare program.