by Cheryl Nash
We’ve all heard it and we all have to do it. Documentation: The necessary evil. For a phlebology practice, each new year seems to bring more lengthy requirements and requests for records. From Ultrasound Reports to History and Physicals; Operative reports to Letters of Medical Necessity; it seems that today’s phlebology specialist spends more and more time dictating, and the requirements keep changing. How does anyone keep up?!
Unfortunately, incomplete documentation is one of the most-common reasons for a phlebology claim to be denied. Many factors must be addressed for surgical treatment of varicose veins to be considered medically necessary. This is standard for all payers nationwide. Some factors are common to all payers, and while there are some variants, most have the same basic requirements. They include evidence of reflux, showing incompetence of the lesser or greater saphenous veins conservative treatment tried and failed, compressive therapy for a variable amount of time and an absence of PAD and DVT. Insurance companies review their guidelines each year and make changes as they see fit. These changes need to be monitored closely to ensure requirements are followed to the letter. Missing even one factor can cause a claim to be denied at all levels of appeal, and ultimately cause a lack of payment for the practice.
Another reason to maintain correct documentation is to protect against audit. RAC audits are being conducted by Medicare and various commercial payers, most commonly Medicare Advantage plans. The importance of protecting yourself against these audits has taken center stage. Audits are no longer a case of “if, they are a case of “when”, and no one wants to be caught unprepared. In addition to auditing, there have been an increasing amount of whistleblower cases that have sparked a wave of record requests from all payers, including Medicare, to verify that the level of service billed is indeed what was performed. More, not less, documentation is the only recourse to survive an audit.
The best defense really is a good offense. Having a comprehensive knowledge of what is needed, and ensuring your standard reports to meet these requirements are key to smooth and timely reimbursement. Presenting a quick and thorough response when an insurance company requests those records will result in faster payment. One of the best ways to accomplish this is to keep a file, whether physical or electronic, of your most common payers’ clinical policies on hand. It is also helpful to note when the next review date will occur. When recommending a course of treatment, have a staff member that is well-versed on these policies review the patient’s insurance and the chart records to ensure each element has been met. This holds true for both follow-up services and primary surgeries.
TMI (too much information) is the rule in this specialty and a brief report that only the doctor can read is not sufficient. If the insurance company cannot read it, they will not pay it. They do not employ staff that specialize in phlebology to review records, and if they are not clear, the claim will get denied. We have all heard the cliché’ “if it isn’t documented, it didn’t happen”. This is so very true with Phlebology. The insurance company is not there to help you and does not want to pay you, so it is up to healthcare providers to actively participate in their own reimbursement. Ensuring that the claim is not denied on a documentation technicality is one of the major ways to achieve this payment goal.
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