Requests for Additional Information from Payor Source?

So your practice has received a request for additional information such as medical records, clinician notes, lab results or procedure phots... how should the request be handled?  Below are a few tips that may make the exchange of information between medical providers and the various payor sources more timely and efficient resulting in fewer dollars returning to the payor sources due to claims process with insufficient supportive data -or- a denial of a previously paid claim due to untimely response to a request for additional information.

1.  Verify that the designated practice contact person's information is correct in the payor source's system.  Names, titles, email addresses, mailing addresses and phone numbers should all be verified to assure the practice receives any Request for Additional Information regarding a previously filed claim.  In the case of the Medicare RAC Auditing process, a medical provider has a limited number of days to respond to a request for additional information from the date posted on the request.  The RAC auditor will mail the request for additional information to the address included in the provider's profile in the Medicare system.  The provider is responsible for the accuracy of the information contained in their profile.

2.  Make certain that the person appointed by the practice to receive the request for additional information understands why the request for additional information has been received, and has a good system in place to respond to the request.  Let's face it folks- if you receive a request for additional information about a reviewed claim, the auditor believes the claim may have been filed in error and is contemplating denying the claim and requesting a refund from the provider.  A knowledgeable practice representative who receives the request for additional information timely and is able to provide documentation that supports the visit/evaluation/treatment within the prescribed timelines will have a positive impact on the amount practices are asked to repay.

3.  Have a claims review process that includes key members of the practice staff who review all requests for additional information- are there trends or lessons to be learned in regards to information that is provided to payor sources that may help reduce the frequency of requests for additional information and/or denied claims as a result of a look back audit?

Please share with us your thoughts on this topic!