You just received "the letter" from an insurance payer. What now? - DoctorsManagement You just received "the letter" from an insurance payer. What now? - DoctorsManagement

Responding to “The Letter”

By Sean M. Weiss, CMCO, CPMA, CPC, CPC-P, CCP-P, ACS-EM

When the dreaded letter arrives from a special investigative unit of one of the big insurance payers or from a ZPIC, MAC, RAC, MIC, etc. your organization should waste little time in working on lining up professional support to help craft your response as well as begin the process of gathering all necessary documents to support the services provided and billed. However, the one question I get over and over is, “What if we cannot legitimately respond by the date requested… what can be done?”

It is frustrating enough to receive a letter demanding medical records from your group… it is even more daunting when it comes from a ZPIC or other agency tasked with finding “Fraud”.

Most who write letters of extension try to create a dissertation and tell them everything that is going on in your organization as to why you cannot possibly respond in time. Don’t do that! The purpose of requesting an extension is to allow the group to perform its diligence to ensure all of the documentation exists, that it is legible and any ancillary information needed to support the claim(s) is captured from outside groups engaged in the care of the patient for the specific date(s) of service.

Additionally, requesting the delay allows your outside or general counsel an opportunity to seek the assistance of a consultant to perform the clinical documentation review to identify any potential areas of concern prior to the records being submitted so that if a defense is necessary the process can begin immediately. It also allows for clarification statements or addendums to the medical records to be generated to make the review of the information easier for the reviewer(s).

The big mistake I see all the time is a letter requesting medical records is received and it sits for days and even weeks before someone looks at it and says, “Oh no, this is due in 10 days…” This creates a lot of issues as you can imagine. Here are my Dos and Don’ts of what to do when you receive a request for medical records:

  1. Do ensure the letter gets to the right person (HIM Director, Practice Manager, Managing Partner, etc.) in a very timely manner.
  2. Contact outside or general counsel to make them aware of the letter and seek guidance.
  3. Do immediately begin gathering all of the documentation related to requested date(s) of service and make (3) copies. One for legal counsel, one for the provider(s) of record and one for the insurance company.
  4. Do create an internal checklist based on all of the documents specifically requested by the payer.
  5. Do have the provider(s) create statements of clarification and/or addendums for anything they believe is lacking in information.
  1. Don’t wait to forward the letter on as these items are time sensitive.
  2. Don’t simply copy the records requested and send them on to the insurance company without first having it all reviewed by the provider(s) of record and legal counsel no matter how innocent you believe the request to be or how complete a job you did at putting the information together.
  3. Don’t send them more than what they asked for. Sending too much information is sometimes worse than not sending enough.
  4. Don’t not respond and hope that the issue will magically go away.
  5. Don’t go back and try to add to the existing note. Once a note has been signed by the provider it is considered closed and any revisions additions or deletions to the original note are prohibited. Please see number “5” under “Dos”

Click the link below to download a sample letter of extension that you can manipulate to fit the needs of your organization. My style of writing for these type letters is to keep is simple…

Download sample letter…