FWA Conditions of Payment
Safeguarding the integrity of your medical record review is critical during a fraud, waste and abuse investigation, as it can be closely scrutinized when there is provider push-back. Conditions of Payment in FWA are often overlooked and can have a significant impact on the outcome of the medical review. This article provides information that FWA leaders should consider when determining what are acceptable reasons to deny payment and recommendations to help safeguard the integrity of the investigative process.
FWA and Conditions of Payment: Safeguarding the Integrity of Your Medical Record Review
Consider this:
If a provider disputes the findings of a medical record review performed by your team, will your reasons for non-payment or denial be appropriately justified and supported by the executives of your organization? If you answered “good question” or “I don’t know” – put this on the top of your to-do list. This all too important question is often an afterthought, or not a thought at all for many organizations, resulting in provider abrasion and concerns raised about the integrity and quality of the medical review process in FWA (fraud, waste and abuse) investigations.
Many of us have experienced the backlash that occurs when a provider disputes the findings of a medical record review/audit. While analytics help provide better identification of improper billing behavior, the medical record review is where the real validation happens. You want to be certain that your basis for denial of payment will be supported by your executives, if escalated, and will demonstrate the integrity of your work if questioned later by the provider or their representative.
In a recent video, we highlighted a few suggestions that FWA investigators and leaders should consider when performing medical reviews related to an FWA investigation. Oftentimes, a review of patient records reveals a laundry list of problems, making prioritization difficult. If internal policies are missing or unclear, how do you decide which issues rise to the level of non-payment or denial?
What are Conditions of Payment?
Conditions of Payment for Federal programs typically represent a rule, regulation, or requirement that must be met for a healthcare provider to lawfully request and receive reimbursement. Where rules and regulations are missing, health plans will benefit from guidelines and guardrails for coverage decisions.
Developing internal guidelines to address common findings is a best practice and facilitates consistent determinations. Here are some suggestions to consider when deciding what justifies a denial and answering the question, “Does this finding represent a condition of payment?”
Will you deny for...
Missing or incomplete patient identifiers on visit notes?
Missing consent for procedures?
Missing or incomplete record authentication by the servicing provider?
Missing or incomplete referrals to specialty providers?
Unsigned or undated orders for diagnostic tests?
Claim lines containing unnecessary billing modifiers?
Incorrect assignment of the Principal Diagnosis for diagnostic tests?
Incomplete medication administration documentation (who/what/when/where)?
Best Practice Recommendation.
We recommend creating a reference guide - which can be as simple as a spreadsheet, or may involve decision trees, qualifying conditions, and quantity/volume/financial thresholds. The National Committee for Quality Assurance (NCQA) has established “Guidelines for Medical Record Documentation” containing 21 commonly accepted standards for medical record documentation for use by healthcare organizations . Consider adding NCQA guidelines and other helpful instructional links to health plan provider handbooks and newsletters but more importantly, consider whether you would actually deny payment if one or more of these are missing and be sure to get organizational support. Dedicating time to identify and define plan-specific Conditions of Payment is an investment in delivering efficient and consistent record review results that safeguard the integrity of your investigative process.
Should you need support in identifying and defining your plan’s specific conditions of payment, we can help. With more than 30 years of experience supporting payers, Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. We provide healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and program integrity entities.
Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. We provide FWA services to payers around the country.
If you need a program assessment, program growth strategy, investigations, medical reviews or training support -- reach out today.
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