Medical Record Reviewers: Do You Feel Pressure to Deny?
As a medical records reviewer, do you ever feel the pressure to deny everything? Integrity Advantage's Terri Riis-Christensen shares her insight on this topic critical to the med review process.
Do you feel pressure to deny everything? Do you spend time looking for reasons to deny? As part of our new Integrity Advantage Learning Series, ‘Relating to the Reviewer’, Terri Riis-Christensen shares her insight and expertise as a medical records reviewer on this important topic.
As a coder, sometimes we’re taught not to look at money, but rather code what is documented. Medical record reviewers should apply the same concept. Does the documentation contain the potential for fraud, waste, and abuse? Based on the information provided, medical reviewers shouldn’t aim to take down providers just because their records are being reviewed.
Denying lines just to deny them sends a message that we are against our healthcare providers.
It can lead to taking resources out of context, which reflects poorly on the medical reviewer.
It provides the possibility of wasting time.
It can promote animosity towards the reviewing entity.
These do not create beneficial relationships
There are going to be valid denial reasons, and those need to be documented as such. However, there will be other items that are less definitive. If something appears to be a ‘one off’, consider:
Does it appear to be outside of the regular practice?
Is it something that the provider may just need to be educated on?
Can I find a credible source to validate my reason for denial, or am I stretching it?
We are on the hunt for bad providers, but we shouldn’t make every provider the ‘bad guy’.
Integrity in the review will soften the stigma and promote providers to look at their practices and apply the necessary changes to be compliant.