Always Supply Medical Records When Requested by the Benefit Integrity Unit

In the course of conducting audits, Palmetto GBA/Railroad Medicare’s Benefit Integrity Unit (BIU) has found many providers fail to respond to records requests.  If the BIU does not receive a response to a records request within 30 calendar days from the date of the request, each selected claim will be denied as not reasonable and necessary.  All previously paid funds will be recouped, and overpayments will be established. Interest will accrue for each overpayment every 30 days. If overpayments are not paid timely, offset from pending and future claims  will begin on the 41st day from the set up date.

Providers may request an appeal of an overpayment; however, individuals who supply records the first time around may avoid unnecessary denials and debt collections.

Medicare Administrative Contractors (MAC) and the Railroad Retirement Board Specialty MAC (RRB SMAC) have the authority to collect records per the following Social Security Act regulations:

• Section 1833(e) states “No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.”
• Section 1815(a) states “…no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period.”

When furnishing your documentation to the BIU, please keep the following in mind:

• Documentation must demonstrate that the patient's condition warranted the type and amount of services provided (i.e., medical necessity)
• Documentation must be legible, even if it is dictated or transcribed 
• The documentation must clearly indicate who performed the procedure or supplied the equipment
• The documentation must be signed, either electronically or via written signature.  Please see the resource below that discusses Medicare’s signature guidelines
• Each service must be coded correctly 
• Send all relevant documentation in your initial response. This will allow Palmetto GBA to review all the facts the first time and may help you avoid an unnecessary appeal later. 

Not all claims are denied for non-response. Other claim denials may include:

• Documentation was lacking/missing required elements
• Documentation failed to support medical necessity

Regardless of the reason, all BIU denials will result in overpayments being set up, and the provider will be responsible for the charges. 

Resources:

• Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices
• CMS Medicare Learning Network (MLN) Fact Sheet - Avoiding Medicare Fraud and Abuse: A Roadmap for Physicians  (PDF, 1.57 MB)
• CMS Medicare Learning Network (MLN) Fact Sheet - Medicare Fraud and Abuse: Prevention, Detection, and Reporting (PDF 2.6 MB)
• CMS IOM Publication 100-08, Program Integrity Manual, Chapter 3 and Chapter 4
• OIG Publication - A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse (PDF, 6.8 MB)