Health Information Management

Make sense of the multitude of auditor requests for medical record documentation

JustCoding News: Inpatient, February 17, 2010

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You receive a letter in the mail requesting copies of medical records for an audit. It looks much like the one you received the day before, but the return address is different. And they both look quite similar to the other request for documentation you received last week.

What is going on? An awful lot of postpayment auditing, that’s what. The government is protecting its dollars, and hospitals have to deal with it.

Not that it’s easy. With recovery audit contractors (RAC), zone program integrity contractors (ZPIC), Medicare Administrative Contractors, and others auditing your Medicare claims, and Medicaid integrity contractors (MIC) examining Medicaid claims, the number of medical record documentation requests your hospital receives could quickly become unwieldy.

And each auditor seemingly has different requirements to meet. You have 30 days to submit documentation to one and 45 days for another. You have to manage discussion periods, rebuttal periods, and appeals.

Who needs what and when? It’s enough to make your head spin.

HIM directors are often responsible for managing and tracking the wide array of requests coming in. Not meeting those requests means the auditor will automatically deny the claim and recoup the money—hardly an option in tough economic times.

“It is important for facilities and physicians to stay on top of these requests,” says Debbie Mackaman, RHIA, CHCO, regulatory specialist at HCPro, Inc., in Marblehead, MA. “In some cases, failure to respond with medical record copies in a timely manner may result in unnecessary recoupment because of the lack of response.”

In addition, healthcare providers who accept payment from government entities are obligated to participate in audits—they aren’t exactly optional, Mackaman says.

Luckily, HCPro developed a chart that we think might help. If you need to know whether a request from a MIC for 350 records is legitimate, how long you have to respond to a Comprehensive Error Rate Testing (CERT) request, or what the ZPIC look-back period is, consult HCPro’s auditor chart to help navigate the maze of record requests and your appeals rights, among other things.

“The chart is helpful to sort out all of the auditors and understand the scope of their audits,” says Mackaman, who helped create the tool. She suggests you share it with any staff members who receive and process these types of requests, including coders and billers.

But staff members should also be sure to review each letter carefully for deadlines, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, who also helped create the chart. Some auditors may conduct audits that are part of new audit programs, for example. But the letter staff members receive will always convey all of the most important information.

“And make sure to review mailroom procedures to make sure the letter quickly gets to the right person,” Hoy says. HIM directors may want to give the mailroom a copy of the chart to help staff members there recognize and pass on important correspondence quickly, she suggests.

Editor’s note: This article was originally published in the February issue of Medical Records Briefing. E-mail your questions to Senior Managing Editor Andrea Kraynak at

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