Back to the Basics of Compliant Documentation

The backbone of success in the revenue cycle starts and ends with compliant documentation. No matter how many articles you read or webinars you attend on documentation, there is always more to learn. Documentation has become synonymous with challenges—and lots of them. Just when you think you are starting to figure it out, a new regulation, requirement or complication rears its ugly head, causing you to pivot, all while remaining compliant and efficient. So how do we tackle this problem once and for all? Go back to the basics.   

There is no secret sauce for success in the documentation world of health care, but there are ways to stay ahead of the game. Here are the top eight things to know:

1. The retrieval process requires the right person in the position.

Choose a staff member (or members) with the characteristics and talents that lend themselves to successful turnaround. Some important characteristics include: good communication skills, the ability to build rapport with referral sources when phone follow up is necessary, tenacity and attention to detail.

These employees are more than documentation specialists; they are your internal sales staff. These key attributes provide the thoroughness needed to stay on task, create relationships and monitor the process for success.

2. Follow diligent follow-up protocols.

An effective tracking system for medical documentation is imperative for increased claims submission and reduced accounts receivable. Be sure that you are keeping these things in mind:

• Employee accountability and responsibility over this area of the business is crucial to success.
• Organization metrics for follow-up are needed to track the timeliness of the return with accurate information.
• Cascade company expectations about goals throughout the organization to ensure that performance will be achieved at every level.
• The follow-up process needs to be adhered to by team members so the revenue that is holding for information is addressed in a timely fashion.
• Using software in the monitoring process with key indicators and reports is vital to keeping your holding revenue down.
• Never let up. As soon as momentum slows down, build-up occurs, and it is hard to recover while attacking the backlog.

3. The vehicle of communication makes a difference.

Providers use a combination of functionalities, such as e-fax and e-prescribe, as well as legacy methods like the phone, walk-in visits and old-fashioned mail, to gain the documentation for claim submission. Certain approaches may net a quicker turnaround, but no matter the conduit, the information still needs to be reviewed for compliance in meeting payer medical policy. Each technique will net different returns based on whom you are working with to gain the applicable documentation. Understand which approach works best for your practitioners, and trend their response/compliance rate to determine the best course of action moving forward.

4. Chart review needs a highly trained team member.

A veteran employee with a firm understanding of the payers and industry is usually the best fit for the job of chart review. Training needs to be a high priority for the job and should focus on the requirements of the payers, understanding medical terminology and the content of the clinical evaluation, and being able to dissect the payer’s medical policy and translate that into the review of the patient’s chart.

Resources and tools found on the CGS Administrators and Noridian Healthcare Solutions websites are great for training purposes. The local coverage determinations are broken down by product category with specific documentation checklists that provide concise information for ease of understanding. Other references are available, so you don’t have to reinvent the wheel of training. Another bonus is that most payers follow Medicare guidelines, so cross-training is at your fingertips.

5. Education is king.

With the advent of audits and increased documentation obligations during the last decade, practitioners have become better at completing their duties in the process. However, they still need education on what payers require for their patients to qualify for services. Communicating with and educating your referral sources is tricky, but the effort still needs to be expended to serve your clientele. Scrutinize which referral sources provide you with the requisite information and have a good turnaround on the request for material. If you have direct access to their electronic health record (EHR) system, this will decrease turnaround time. If the correct charting is not in the EHR, you will still need to communicate with their office.

6. COVID-19 became a “silver bullet” for some documentation requirements.

The public health emergency (PHE) brought many trials, but it also brought some relief in terms of documentation. The industry gained a reprieve from certain clinical documentation burdens, such as:

• Clinical indications for coverage found in respiratory, infusion pump and therapeutic continuous glucose monitor NCDs or LCDs not being enforced
• CMS determining that the requirements for a certificate of medical necessity for oxygen and a DME information form for external infusion pump claims would not be enforced during the pandemic
• Medicare suspended audits for five months in 2020
• Signature requirements on delivery tickets were waived during the PHE

7. Audits are on the rise.

As the country and industry have progressed through the PHE, we are now seeing some of those relaxations in documentation coming back to life. One such area is in the realm of audits. Audits are coming in not only from the governmental payer side, but also from the private sector. Optum and Performant have stepped up the pace, and providers are being burdened with multiple claims daily that need to be processed. Your success rate is directly related to the documentation you have within your files.      

8. Be ready for business as usual.

As available vaccines gain momentum, be ready to return to pre-PHE regulations. Operationally, be prepared to go after the face-to-face evaluations and gain signatures on the documents that had previously been given a pardon. Team members will need to be updated and retrained on the old directives to carry out their responsibilities in accordance with the post-PHE environment. Stay vigilant in education and training.

You may feel like the difficulties that surround documentation only pertain to your company or affect your area of the country or niche market, but it is a global problem all providers deal with. You are not alone, so take heart—it is the state of the industry. Hopefully, as technology and the evolution of health care march forward, the paperwork burden will ease up. Remember, it is all in the details, so cross every “t” and dot every “i” and you will see your holding revenue decrease and audit compliance rates increase.