I was sitting there looking at a $40,000 clawback.
And I didn’t do anything wrong.
The insurance company was under pressure to increase its recovery rates under its internal audit systems, so as to prevent a more intrusive examination from the outside.
So they applied the latest documentation regulations to documentation on visits performed 4 years old—long before those regulations had been created, let alone approved.
If I appealed, I was told, I would be working directly with CMS rather than the insurer.
My documentation was 100% defensible, but you already know what I decided.
From then on, whenever I could, I referenced my documentation directly to the literature. Yes, this was one more step, one more macro to create and import—but it paid off big time.
The next time I was targeted for a clawback, I brought out the references and the matter was quickly dropped—and this time, five figures were retained.
Document to fact, to the clinical definitions—not to ephemeral current documentation guidelines.
If your insurer tells you, “You don’t need to document Major Depression based on the DSM-V criteria”—do it anyway.
Four years from now when enforcement ramps up, your documentation will be held to the higher standard and you’ll be compelled to give back the associated revenue—I have seen it over and over again.
So be thorough and be complete, don’t listen when your insurer or compliance professional says you can ease up—I’ve been through the wars, they have not.
Document to reality, beyond guidelines.
You’ll be very glad you did.
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