you are a third party payer performing medical record review you notice a procedure that was not done what should you do
As a third-party payer performing medical record review, if you notice a procedure that was not done, there are a few steps you can take:
1. Verify the information: Double-check the accuracy of your observation by reviewing the relevant medical records and documentation. Ensure that the procedure was indeed not performed as indicated.
2. Consult the billing and coding guidelines: Cross-reference the procedure code with the corresponding documentation requirements outlined in the applicable coding guidelines. This will help you understand the necessary criteria for a given procedure to be considered "done."
3. Contact the healthcare provider: Reach out to the healthcare provider who submitted the claim. You can do this by sending a written request, such as via fax or email, asking for clarification regarding the procedure in question. Include any supporting evidence or documentation you have gathered.
4. Request additional information: If the healthcare provider confirms that the procedure was not performed, ask them to provide an explanation for the discrepancy. Request any missing documentation or any other relevant supporting materials that could help you investigate the situation further.
5. Review the contract or agreement: Examine the contractual agreement between the third-party payer and the healthcare provider. Look for provisions or clauses that address non-performance of procedures and the associated billing implications. This will help you understand the steps and actions you can take in such situations.
6. Adhere to company policies: Follow the policies and procedures set by your company or organization regarding the handling of situations where a procedure was billed but not performed. This may involve initiating an internal investigation, communicating with relevant stakeholders, or taking further steps as outlined in your company's protocols.
7. Report the findings: Share the findings of your investigation with the necessary parties, such as your supervisor or claims review team. Provide them with all relevant documentation, including any communication with the healthcare provider and supporting evidence.
Remember, it's important to approach these situations objectively, ensuring fairness for all parties involved while upholding the applicable industry guidelines and standards.