Effective Medical Reviews: An Interview with Integrity Advantage Medical Reviewers
What do the following have in common: Communication/Relationships, Access, Organization and Conditions of Payment?
They’re the building blocks of an effective medical review. Listen to this discussion for a firsthand perspective from our clinicians and coders!
Good morning, everybody and our LinkedIn friends!
Thanks for joining us today. So, in follow-up from our poll, Jala had posted a poll about content. She was asking if we wanted to (or y’all wanted to hear about med review, investigations, data, or program setup, (I think it’s how she phrased it), med review won.
So, I have some lovely guests that are some of our Rockstar med reviewers, and we’re going to talk today a little bit about the process and things that we can learn and kind of launch off of for further content as we kind of explore med review tips, tricks, techniques. And, yes, I did listen to you if you voted on my poll that said you’d prefer articles over videos. Sorry, we’re doing a video, because I talk better than I type, but we will follow up with articles that you can read. (so, we’re going to do a video right now even though you voted against it.)
So, ladies, thank you for being here today!
(Thank you for having us!)
Question 1: Can you tell me about a time when you received a medical record review and it didn’t give you what you needed?
Deanna Sipp, CPC: I was going to say, “I can take that one!” One thing I find problematic in review is when the sample doesn’t give the information needed to support or to rule out the allegation. An example of that might be if the allegation is, let’s say improbable service times, and the sample pulled only provides limited billing hours per date of service, then it’s unlikely that I would be able to substantiate or to rule out that allegation.
Jessica Gay, CPC, AHFI, CFE: Ok, so I’m thinking from an investigator’s standpoint, we’re looking at impossible day. I pulled a statistically valid random sample and if my sample unit is not a date of service, which is different than most of the time that we would do a sample. So instead you’re seeing a bunch of visits across the scope instead of an entire days worth of services so, therefore, you can’t see if it’s impossible or improbable.
Deanna: Exactly!
Jessica: Gotcha! So, what can an investigator do better to kind of avoid that? To give you that ability to substantiate or refute an allegation.
Deanna: I think one of the easiest and the most beneficial fixes is a collaboration with the medical reviewer and the investigator to kind of determine what specific components or data need to be pulled in order to work that case.
Jessica: Ok, so just reach out, talk. Amazing how many things are solved with good communication! My very first case (a little impromptu story because that’s how I roll), it wasn’t my very first case, but one of my first cases, I remember my med reviewer, I got my review back and was like, “you didn’t talk about my allegation”, and it’s because it was PT and I did similarly, I didn’t sample by my member, so they couldn’t see the progress of care, so they couldn’t see if it was excessive services, because I gave them random chunks of some of some of these visits instead of the progress over time. So, been there done that. I think most of us have made some of these pitfalls or mistakes in our career. So, I think kind of on that note, Question 2 is a kind of piggy back, right?
Question 2: What makes a review go smoothly or even what causes frustration?
Jessica: Terri, what does make a review go smoothly versus what can cause frustration for the med reviewers?
Terri Riis-Christensen, CPC: I think you know me by now - that documentation is my big thing. So, I mean ultimately, you know when you receive a medical record and the doctor has no cloned information and he’s initialed and dated all the reviewed sections, that would be awesome.
But realistically, kind of in what we’ve been talking about so far is:
Good resources
Clear policies
Knowing the hierarchy of the policies
The rules/laws that we’re going to be following
I mean, these are the foundation of the reviews. So, once we know what the specialty is and allegation is that we’re going to be looking at, obtaining good resources is the easiest way to start off smoothly. As Deanna and you were just talking about, the review sheet (when it includes all the information that’s necessary to perform a conclusive review), that way you’re not having to search for the information or request information, but should you have to, again, as you guys were talking about communication/collaboration with the investigator, the accessibility of them. Those are all the things that can help it go smoothly.
Then on the frustration side, the opposite of everything!
Lack of policies,
Lack of access to policies, especially when you’re looking at older dates of service.
We know that post-payment reviews can go back a few years and without having those older policies, we’re not going to have as quality of a review. Then organization of materials. So the biggest thing probably is medical records, you know, your review can have a couple of people or tens of hundreds of people depending on how big the review is what they’re looking at. You know if you don’t have organization in the materials provided / the records provided, if you send one PDF with everybody on it with all the dates of service, versus sending each member separately with date of service order. So, that can be a timely factor in how we perform our review.
Also, one of the other things is multiple lines of business in the review. When you’re having to change your thought process from Medicare to Medicaid to commercial. So, those are some of the frustrations.
Jessica: Yeah, makes a lot of sense. And I think, you know, I tend to focus on my spreadsheet, making sure it has your diagnoses, your procedure codes, your units, that sort of thing and there’s a lot less focus as an investigator on the medical records, sometimes it’s like, “oh, as they come in”, but yea, we all want our stuff done first and say, “well, where is my med review in the list?” Because we’re anxious to get our case going. So, I think really taking consideration of what you guys need to make it smoother and go more easily benefits us all. Awesome! Alright, Mo, you’re up! So, speaking of lines of business, we support a bunch of different clients across the country. So we have a varied geography as well as lines of business. But what are some of the pros and cons of supporting those multiple lines of business, geographies, Health Plans, etc.?
Question 3: As a vendor, we support many clients - what are the pros and cons of that?
Monique Mays, LPN, CPC: The benefits of supporting multiple clients is that we have an opportunity to see how billing trends change in different regions and markets. Like Terri said, we support all lines of business so, we have to take all that information and we’re able to utilize it and apply our knowledge to support client reviews. On the other side of that (I don’t want to say unfortunately, because it’s all good! You learn, It’s the business, it’s constantly changing) So even though you might have the same allegation or code, you really have to focus on the hierarchy of billing guidelines. It’s possible an update on a policy will occur affecting the findings of our review. So as you are assisting a client, depending on what line of business you’re looking at, not trying to say anything about COVID and how the guidelines change, you know, you could be doing a pre-pay or a post-pay review, and it’s up to you as the medical reviewer or the investigator to make sure you have the correct resources and the current guidelines and make sure you’re looking for information in the right region, because it’s not like I ever applied an LCD from one region to another because I would never do that, I don’t make mistakes. So, you know, this is very important because you want to make sure you are giving the best quality and efficient review and findings to the client. So, sometimes it’s a lot to, you know, pull all that together.
Jessica: Sure. I mean, it is nice that we are an industry of perfect humans so that there isn’t those mistakes that happen and there’s no gray area in what we do either on the data or investigations or the medical review. So, we’re really, really lucky to work in an industry that is, you know, black and white. Perfect.
Monique: It’s a perfect world to work in and an industry to work in. You know you get alerts when codes and guidelines change. So you know, “oh look, that’s changed. I should stop and focus on this and go in a new direction.” Doesn’t happen.
Jessica: Definitely not! Alright, so it sounds like a couple of themes:
Collaboration & communication
Which is like the number one theme of everything that we talk about all the time it feels like sometimes.
Good relationships
I mean even just that, we laugh but if you’re not comfortable or somebody’s always like, “this investigator always a little snarky or lippy every time I call her,” are you likely to pick up the phone and call that person? And vice versa - are we likely to collaborate with our Med review team if we don’t really want to hear what you say? So, having that relationship, that trust in place, I think is crucial.
Organization
I think is so important: the spreadsheets, the records, even just the naming, splicing those is huge.
Policies and Conditions of Payment
Each plan kind has different levels of aggressiveness as far as you know, what do they consider a condition of payment? Do you have to have an image for everything that says it needs an image, or are they a little bit more flexible on that?
Access
Whether it’s access to people or resources, policies, whatever that is. Just making sure that we have the appropriate resources.
The Medical Reviewers: “I would agree. Yeah, Great. Yeah, just staying on top of everything. - that’s just what we do!”
Jessica: That’s what we try to do! Alright ladies, I think that’s a wrap. That’s it for today and we’ll see if anybody listens to us if we do it again!
Monique: Yeah, listen, we’re great people-you’re going to love us!
Jessica: That’s right - bye y’all!
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