HGSAdministrators (HGSA), a Medicare Part B contracted insurer, has shared the following information with PCPA for distribution.
In recent months HGSA has seen an increase in the percentage of dollars that were paid in error as a result of insufficient documentation being submitted to the CERT Contractor, AdvanceMed. Under the Comprehensive Error Rate Testing (CERT) Program, carriers are required to seek refunds for services for which insufficient documentation was provided. Many of these CERT errors and refund requests can be avoided by submitting all necessary medical record documentation to AdvanceMed.
AdvanceMed's record request letter includes a list of medical record components that may need to be submitted. These include:
- Physician Progress Notes
- Physician Orders
- Nurses Notes
- Medication Records
- Graphic Reports
- Operative Reports
- Pathology Reports
- Consultant Notes
- All Lab Reports
- Diagnostic Test Results (regardless of where performed)
- History and Physical Notes
- Hospice Records
- Home Health Progress Notes
- Certificate of Medical Necessity
- Skilled Nursing Facility Records
- Ambulance Records
- Emergency Room Records
This is not an all-inclusive list. In addition to those components that would apply, please make sure to submit any additional medical record documentation (treatment plans, physical therapy progress notes, etc.) that substantiate each of the services billed to Medicare.
Some of the documentation that would substantiate the services billed to Medicare may reside with another provider/health care facility. It is incumbent upon the physician/provider receiving the CERT medical record request (and payment for the service) to send all of the necessary medical record documentation to the CERT contractor, regardless of whether or not that documentation is physically located with the physician/provider who received the request.
Insufficient documentation errors are most frequently associated with subsequent hospital visits and are often the result of the omission of physician progress notes. For subsequent hospital visits, physicians/providers must submit progress notes and all other essential documentation, even if these portions of the medical records are stored with the hospital.
Insufficient documentation errors are also frequently associated with lab tests, consultations, and nursing home visits. Coordination with other providers/health care facilities to obtain the necessary medical record documentation for AdvanceMed is imperative. Services will continue to be denied and refunds requested when all medical record documentation is not received by AdvanceMed.
