Medicare records review:  problems will continue for those who document poorly

 By Paula Hartman-Stein, Ph.D.

        A widely circulated story on the Internet recently described CMS (Centers for Medicare and Medicaid Services) as backing off from its hard-line approach to claims denials.

        When asked if CMS was adopting a gentler approach to providers’ billing errors, Kevin Gerold, DO, JD, acting deputy director of Program Integrity at CMS, responded, “Our review process has not become kinder or gentler. We are instructing contractors to permit their nurse reviewers, when looking at medical records, to interpret that record in the context of the care provided. But it is in no way an attempt to overlook poor documentation or to overlook something that is not there…People who document poorly will continue to have problems.”

        Operation Restore Trust (ORT), the initiative of the Office of Inspector General (OIG) to conduct audits of Medicare Providers’ records to discover potential fraud and abuse, has represented one end of the spectrum of the federal government’s methods of ferreting out criminal providers. “We recognize that the vast majority of providers are honest and intend to bill Medicare correctly, Gerold said. He acknowledged that under ORT there may have been some blurring of lines when practitioners made unintentional or uninformed mistakes in billing in contrast to blatant attempts at fraudulent billing practices. “If you make a mistake, you are not going to jail.” 

        Several years ago ORT reviewers found a 15% overall error rate for claims, and according to Gerold the error rate has recently dropped to 6%.  

        Mark Regna, the Interim CEO of Assured Behavioral Health in San Antonio Texas agrees that practitioners who make unintentional mistakes may not be incarcerated, but he knows several psychologists in his company who lost their jobs because auditors alleged errors in their documentation and billing procedures.

        “In school they teach psychologists how to save the world, but they need to learn how to save themselves,” Regna said in a recent phone interview.

He minced no words when describing the ignorance of many psychologists in the business aspects of psychological care. He believes the American Medical Association does a much better job than the APA at educating its members about proper coding procedures. “Psychologists need to worry less about where to set up the chairs in their office and more about the meat and potatoes of business, how to bill properly.”

  Gerold acknowledged that mistaken billing requires the provider to pay back the amount of money paid under Medicare, with interest. Congress sets the interest rate in law. In a January 25, 2002 Federal Register report the Department of Health and Human Services is proposing that overpayment of claims be paid back to the government in 60 days.

            The OIG website shows that over 400 psychologists have lost their status as Medicare providers for various reasons including fraudulent billing in Medicare and Medicaid.

            An appeal process before an Administrative Law Judge is available when the provider disagrees with the determination that a claim has been incorrectly paid. Gerold noted the process favors the person who raises the appeal. Sources suggest that the appeals process is backlogged and overwhelmed, one possible reason that nurse reviewers have been instructed by CMS to review the whole medical record before judging that a claim is incorrect.

Currently 5% of Medicare claims are reviewed. Gerold says that CMS’ tools to find those who intend to defraud the system is getting better and more refined. He denied that the Medicare financial intermediaries receive incentives to deny claims. “As part of our ongoing audit activities, contractors are found in error if they pay claims that should have been denied, or deny claims that should have been paid,” according to Gerold.

Practitioners with “niche” practices will likely show up statistically as outliers, compared to their peers in the same geographic area. But being an outlier does not imply wrongdoing. It may trigger a probe sample to test the validity of the claims. Gerold explained that less than 30 chart entries may then be reviewed. If that sample shows a problem, then the auditors go to a statistically valid random sample.

            Gerold reiterated that CMS is trying to be more sensitive to the good provider. “The default position is to pay the claim,” he said.

            According to Gerold, CMS is providing more effort to educate the financial intermediaries and the providers. “Most providers have to master fewer than 10 CPT codes.”

            “Historically Medicare as a program was intended by Congress to serve as a limited benefit,” explained Gerold. “The perception by the provider community is that it is comprehensive. This causes disconnected expectations between CMS and the practitioners.” 

Paula Hartman-Stein is a psychologist and consultant in Kent, Ohio. She can be reached through her website,

             Hartman-Stein, P.E. (2002) Medicare records review: problems will continue for those who document poorly. The National Psychologist, Vol. 11, No. 2, p 8.