July 28, 2011



Thank you for Tuesday's email about record requests by an insurer. I wasn't sure where to send this question but thought after receiving that, that you may be the right person. I am receiving record requests from an insurer for each patient for each claim I submit. I now have my girls spending too much time making copies and I am wasting tons of resources. Why is this happening and how do I stop this?

Thanks, Steve


Steve, it sounds as though you have been placed on what insurers call "pre-payment review". Pre-payment review is where you have been flagged by an insurer for submitting potentially improper claims (or documentation for such claims) and you are now under review for everything you send in. Of course, being flagged and adding extra review to your claims has probably also slowed down you reimbursement, and potentially dramatically impacted your cash flow. Unfortunately I have no quick fix for your pre-pay review situation. Basically until such time as whatever you are doing that has caught the insurers attention is stopped, you will remain on review. The best advice I can give is to either on your own, or with the assistance of counsel (I recommend with counsel so that you are operating on a level playing field and not being taken advantage of by the insurer) is to open the lines of communication as soon as possible to best understand why you are on review. Once you have modified your documentation and evidenced same, you should be taken off of review and no longer have to submit additional documentation.

Another step you may want to look into (that I highly recommend) is to hire a professional coding expert to come in to your practice to take a look at your documentation. I recommend getting an objective perspective on your documentation at least once a year even if you are not experiencing pre or post-payment issues. Doing so may keep you off of an insurers radar. Remember, par and non-par alike are subject to record reviews - as anyone providing care that is reimbursable may be implicated in misrepresenting fees if the services billed for cannot be substantiated as having been rendered.

For a recommendation of a coding specialist, feel free to email or call me.


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