You’re an HMO director. You would like to ensure that you managed care plan is meeting industry standards. What’s one way that you can do this?
You work for a third-party payer performing medical records review. Your job is to match codes that were submitted on the claim to documentation in the medical record. You notice that a code has been input for colonoscopy procedure, but you don’t see the procedure report anywhere in the record. As the third-party payer representative, what will your action are regarding the code that was submitted on the claim form?
As an HMO director, one way to ensure that your managed care plan is meeting industry standards is to conduct regular audits and reviews. This can help identify any areas of non-compliance or inefficiency within your plan.
To address the issue as a third-party payer representative, if you notice that a code has been submitted for a colonoscopy procedure but the supporting documentation is not found in the medical record, there are a few actions you can take:
1. Contact the healthcare provider: Reach out to the healthcare provider who submitted the claim and inform them about the discrepancy. Ask them to provide the missing procedure report or any additional documentation that supports the code.
2. Conduct a medical records request: If the provider does not provide the missing documentation upon request, you can initiate a formal medical records request. This can be done in compliance with the Health Insurance Portability and Accountability Act (HIPAA) guidelines and the payer's policies.
3. Review payment guidelines: Consult the payment guidelines established by your organization or the industry standards to determine if the specific code requires explicit documentation for reimbursement. If it does, proceed with caution and follow the appropriate protocols to ensure compliance.
4. Evaluate the claim: Examine the claim thoroughly, considering the available documentation and relevant guidelines. If the documentation remains insufficient or does not adequately support the submitted code, you may need to deny or adjust the claim accordingly.
5. Provide feedback and education: Use this opportunity to provide feedback to the healthcare provider on the importance of accurate and complete documentation. Offer educational resources or guidance to help them understand the requirements and improve their future claim submissions.
Remember, it is crucial to follow the established protocols and guidelines while maintaining clear communication with the healthcare provider throughout the process.