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February 3, 2016

No, Insufficient, and Untimely Response to Requests for Medical Records – The Need to ACT

A large contributor to the error rate continues to be failure to respond to requests for medical records. When documentation is provided, it is often not submitted timely (within 45 days for PCA review), the information is incomplete, or it is incorrect.

All of these examples can result in the denial of the service(s) under review.

This triggers additional corrective actions, which may include:

  • Education,
  • Requirement of a Corrective Action Plan (CAP),
  • Overpayment recovery, and
  • Prepayment review implementation.

The initiation of the three latter corrective actions imposes additional costs on both the provider and the MAC; something neither party desires.

To mitigate these added costs, CGS recommends providers stress to their entire organization the importance to ACT:

Accurately, Completely, and Timely respond to requests for medical records from all CMS contractors. 

CGS recommends providers regularly educate staff regarding Additional Documentation Requests (ADR). CGS suggests the education include:

  • How to identify ADRs.
  • The process for ensuring ADRs are directed to the correct personnel swiftly.
  • Procedures for Accurately, Completely, and Timely responding to each type of ADR request.
  • Instructions to ensure the provider to whom the ADRs (and review results) letters are addressed receives a copy of the correspondence.
    • Occasionally, we find performing providers are not aware PCA review is or has taken place.
    • It is important for each individual to recognize they are ultimately responsible for the services submitted on their behalf for Program reimbursement.

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