We have 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 carrier (pays Part B provider claims) and fiscal intermediary (pays Part A provider claims), are known as the affiliated contractor (AC), distinct from a program safeguards contractor (PSC). As a general rule, a PSC is accountable for reducing fraud and abuse in the Medicare program; an AC is responsible for reducing the Medicare fee-for-service claim payment error rate. Of course, there may be overlap in responsibilities and programs.

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). Though they do not pay claims directly, the quality improvement organizations (QIO) in each state have inpatient acute care hospital claim review responsibility, as well as other initiatives that may entail medical review. Two special PSC contractors administer the Comprehensive Error Rate Testing (CERT) program, and systematically request records for medical review. Also, 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 AC requests records in the prepayment development of a claim.

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

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.

PSC and OIG – Programs to prevent fraud and abuse.

FCSO paid over 90 million claims in fiscal year 2007 for Part A and B providers in Florida and Part B providers in Connecticut. Fortunately, only a small percentage of these claims require 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 Customer Service Center at 1-888-664-4112 (FL Part A), 1-866-454-9007 (FL Part B), or 1-866-419-9455 (CT 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.