Editor’s note: This article was submitted by the Texas Office of Inspector General as part of a campaign to help educate physicians and other health care professionals on how to identify and avoid common billing mistakes. Physicians should consult with their own retained counsel.
The Texas Health and Human Services Office of Inspector General (OIG) relies on provider record reviews as a primary tool to identify potential fraud, waste, and abuse in Medicaid-supported services. Reviews typically focus on comparing clinical records, including lab work and treatment notes, with Medicaid billing and payments to verify that the treatments provided and billed to Medicaid were medically necessary. Physicians and other providers are required by their, or their employer’s, Medicaid enrollment contract to promptly provide the OIG with a patient’s clinical record if the patient’s treatment by a physician or a supporting provider is under review.
What the Texas Medical Board and OIG require
Patient records should be accurate. A clear narrative that ensures continuity of care for the patient also supports billing. Texas Medical Board rule 165.1 outlines the documentation that should be included with each patient encounter.
The OIG relies on similar documentation during a medical record review, audit, inspection or investigation. The basics include but are not limited to:
- All documentation for the day of service,
- Patient complaints and symptoms,
- Labs, and
- Treatment plan and progress notes, including prescriptions.
As part of an investigation, an OIG records request will include the documents listed above, as well as prior authorization, referrals for specialty care, lab referrals, procedural notes, and a variety of business records. Additional specific items may be requested, depending on the services under review.
It should also be noted that there may be greater record and documentation requirements than rule 165.1 for a given paid Medicaid service. For this reason, physicians are encouraged to stay abreast of any changes to the Texas Medicaid Provider Procedures Manual.
OIG investigations
The OIG investigates a physician typically after receiving a complaint from a patient, managed care organization, or a utilization review of Texas Medicaid services. When a claims data review raises concerns or questions, an investigator requests records from the physician or practice. An OIG survey nurse will review the records to verify technical compliance with billing. Where medical necessity or a quality-of-care standard is questioned, a physician from Texas Medicaid’s claims administrator will conduct a peer review of the records and the survey nurse’s initial findings.
A case is closed without further action if patient records justify the billing and payments. If billing errors are found in the peer review, follow-up actions can include but are not limited to:
- Recoupment of Medicaid overpayments,
- Education,
- Prepayment review of claims,
- Penalties,
- Termination or exclusion from the Medicaid program, or
- Referral to the Texas Medical Board or the Texas Office of the Attorney General.
Providing physicians have the right to appeal alleged billing or performance deviations.
In an example of an alleged violation that resulted in a settlement, a physician agreed to pay $20,000 for allegedly billing for office consultations using higher Evaluation and Management (E&M) codes than were justified by the clinical documentation provided. OIG alleged that the Current Procedural Technology (CPT) code submitted required a higher complexity of medical decision-making than the reviewed records indicated, and the documentation did not meet the requirements for the billed E&M code. The OIG review of patient files also alleged billing for diagnostic tests without sufficient documentation or clinical indication to justify medical necessity for those exams.
In another instance, a practice self-reported errors that included upcoding some E&M services for which the supporting documentation did not strictly comply with CPT Manual E&M documentation guidelines. And in some cases, parts of handwritten narrative documentation were difficult to read or illegible. The practice agreed to repay Medicaid approximately $200,000 over a five-year period.
Additional resources
Physicians can consult the CPT® Assistant for additional guidance on coding or documentation requirements. The Centers for Medicare & Medicaid Services offers detailed guidelines on documentation in its Evaluation and Management Services Guide. Physicians will find more information on recordkeeping in the Texas Medicaid Provider Procedures Manual and the Texas Administrative Code.
Everyone can play a role in protecting patient care and taxpayer dollars. If you suspect fraud, waste, or abuse in health care delivery, call the OIG Fraud Hotline at 800-436-6184 or use the fraud reporting form on the OIG website, ReportTexasFraud.com.
NOTICE: This information is provided as general information and is not intended to provide advice on any specific legal matter. This information should NOT be considered legal advice and receipt of it does not create an attorney-client relationship. This is not a substitute for the advice of an attorney. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.
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