Five Ways to Take Your Medical Review Process to the Next Level

Introduction

Medical reviews play a critical role in a fraud, waste and abuse (FWA) investigation and the time involved in reviewing records can be extensive. It’s important to spend that time wisely. There are several options to choose from, but finding the right balance for your organization may require youtothinkdifferentlyandemploydifferentmethods. Thisarticlewillhighlight5thingsyoucan do to take your medical reviews to the next level.

How good is your medical review process?

Before you dive into this article, take a moment and think about your existing medical review process. Although it might be hard to know exactly where your process stands in comparison to other SIU teams, ask yourself some questions and see how many you answer with "no."

Do you have a process that prepares your medical reviews for an auditor?
Are results of the medical review tracked and easy to aggregate for reporting?
Do you have a centralized repository for resources and references that can be used by your medical review team?
Do you prepare a comprehensive summary of findings after a medical review is completed that can be presented internally or externally?
Do you often find additional benefits in the medical review that are used to make organizational improvements?

If you answered "no" to any of these questions, keep reading, this article is for you!

#1 First – Always Prep

Before starting, spend the time necessary to understand the request. Don’t operate in a bubble. Meet with the investigator to ensure you completely understand the allegations and how the claim sample was generated.

1. Discuss pertinent details

Are the allegations clear?
Are all known or suspected issues related to the subject identified?
Are credentials and provider specialty verified?

2. Take a quick look at the records

Were appropriate documents requested and received to address the allegations?
How will missing records be addressed?

3. Look at the data

Are claim line details sufficient for member identification and to address the allegations? (Name, date of birth, date of service, billed codes, billed quantity, payment details, etc.)
Is there any data missing that is needed to accurately complete the review?

4. Confirm expertise

Does the review assigned match the expertise and availability of the auditor?
If not, does the auditor feel confident that they have the resources available to accurately complete the review?

Tip: It's best to get the answers to these questions before you start the review. This reduces errors and misunderstandings while fostering a collaborative team environment.

In upcoming articles we will talk more about collaboration as well as medical review considerations to keep in mind when pulling your SVRS, so stay tuned!

#2 - Gather Resources

Obviously, we know that citing resources and developing relevant expertise are important to making appropriate decisions during a medical review. What we are suggesting is not simply citing your references but gathering your resources in an efficient way, so you make the most use of your time. Putting this information in a place where other medical reviewers in your organization can leverage it saves everyone the hassle of searching for a reference that someone else might have already found.

There are an unlimited number of references and resources that can be used for a medical review. Consider pulling together:

Health plan coverage documents and medical policies (member handbook, provider handbook, plan brochures, health plan website links)
Federal and state coverage documents including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), region-specific Medicare Administrative Contractor (MAC) guidelines, and state Medicaid directives
Coding references and tools to evaluate appropriate diagnoses, procedures, and services
Online research for allegation-related billing, coding and FWA issues
Information from professional organizations with industry and specialty-specific standards and guidelines
FDA approval information for drugs and devices
Helpful information may also be found on provider websites and equipment manufacturers.

This is not an exhaustive list. Use this as a starting point for researching and gathering references. Retain and report the URLs for online references and citations.

Tip: Don’t forget to match policy and guideline effective dates to the dates of service in question.

#3 - Create an Efficient Audit Tool

During the entire time we’ve been in the FWA industry (decades now, but who’s counting?!) there has been a quest for the perfect tool to perform, track and report on medical record review findings. While we may remain on that quest for a while longer, we suggest you consider building out capabilities for an audit tool in Excel. This will streamline the process, allowing you to capture and retain results in a reliable, easy way. It also lets you search,sortandfilterresults. Thereviewermayfindithelpfultogroupclaimlinesbyuniqueattributes(alllines associated with a member, date of service, code, modifier, etc.) to simplify the review process.

Consider checklist-style data entry using columns in Excel to categorize and quantify individual review elements. Short answer and drop-down menu options promote quick data entry and facilitate aggregate reporting, shown to the right. Add, remove, and change column headers to customize the review tool, or create a standardized worksheet to meet your specific needs.

Create column headings to ask questions that will address the allegations. Questions that can be answered using brief, unequivocal responses are best. For example, when coverage limitations exist, consider using key criteria as column headers. Limit free-text comments to vital words or phrases and if the vital words or phrases become repetitious, add a new column.

Also, add columns to capture other valuable reportable information. It is common for medical reviewers to identify report-worthy issues not captured in the allegations. If the issues can be counted, add more columns and track them within the audit tool. To manage time wisely, remember to utilize the audit tool to categorize and quantify concerns; use the summary report to tell the story. (More on that in a minute)

Consider these column headings and drop-down menu suggestions or develop your own. The possibilities are endless, and these can be real time-savers:

Provider: performing, referring, supervising, location, credentials
Signatures, consents, referrals, proof of delivery documents: acceptable, unacceptable, missing, illegible, undated, unsigned, incomplete
Codes: acceptable, definition met/not met/partially met, wrong code billed, up-coded, down-coded
Modifiers and quantities: acceptable, correct, incorrect, missing, incomplete
Coverage criteria (defined in column header): met, not met, partially met
References: health plan policy #, LCD #, NCD #, name of professional organization

#4 - Be a Storyteller

As with any document, the style and format of medical review results can vary. Internal reports may look quite different from summaries that are created for recovery demand or education. Some of the best medical review summaries we’ve seen tell a clear story and typically describe audit findings numerically with a narrative synopsis.

SUMMARY REPORTING TIPS:

Start with the framework. Explain the what, why, and how elements of the medical review. List the allegations and describe the documents submitted for review. Provide the review parameters (validation of diagnoses, codes, payments, etc.) and provide the adjudication references (coding guidelines, NCCI edits, Health Plan policies, CMS guidelines, etc.)

Let the numbers speak. Report numeric findings near the top of the report affording an at-a-glance look at lines reviewed. In the body of the summary, you can specify the numbers of claims or lines requested for med review, thenumbercompleted,andassessmentoferrorrateoroutcomedescribedasapercentageofthetotal. For example:

Summarize near top of report

For the body of the summary

Create a reader-friendly narrative. Reports are much easier to digest when you can tell the story in a reader- friendly way. The narrative should summarize the data and any other information gathered during the review.

#5 - Upsell the Results

Since medical review is just one step in a multi-step process, give yours some added oomph by taking it a step further than just a review of the claims. There are ways that you can help other parts of the organization benefit from the insights gathered.

Consider adding a few things to improve the value of the medical review outcomes to your team or organization:

Provide a list of recommendations to facilitate next steps
Highlight any health plan process improvement opportunities (prevented losses!)
Make recommendations for internal or external referrals such as care management or law enforcement
Offer topics and resources for provider education
List all reference documents and citations used in the review, supplying URLs when possible

Not everyone knows how to make medical review results valuable beyond the allegations being investigated. Challenge your team to take it a step further. Adding recommendations based on your knowledge and expertise will help, regardless of whether it's used for education, recovery or referral to law enforcement.

Wrap-Up

The process of reviewing medical records is not a one-size fits all. Of all the components of an SIU investigation, this one can be the most important. If you leverage one or all of the suggestions we've outlined in this article, while focusing on the accuracy of your review, you'll find that outcomes will have more value in the long run.