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For practitioners billing in facility settings, medical recordkeeping is required

Recently, Magellan’s Special Investigation Unit (SIU) has reported several cases in which practitioners are not maintaining records for services rendered in a facility/nursing home setting.

Remember to provide and bill only for services to members that are medically necessary and consistent with applicable requirements, regulations, policies, procedures, and record-keeping standards required by law and supported by Magellan standards.

Providers are solely responsible for their own adherence to applicable medical record obligations set forth by state, licensing board, and/or health plan requirements. Providers are expected to maintain appropriate documentation for all claims billed to Magellan to ensure accuracy of records and enable proper reimbursement under the terms of the patient’s health plan.

Practitioner responsibility in record keeping

While the importance of medical record keeping is universally acknowledged, there exists a common misconception regarding its ownership, particularly in the context of practitioners rendering services at facilities under their own tax identification number. It's imperative to clarify that in such scenarios, maintaining accurate and comprehensive medical records is the responsibility of the practitioner, not the facility.

Clarifying the misconception

Practitioners who bill for their services using their own tax identification number as a separate entity are essentially operating as independent entities within the facility. In this capacity, they assume full responsibility for the care they provide, including the documentation thereof. While the facility may offer administrative support and infrastructure, the onus of ensuring the completeness, accuracy, and confidentiality of medical records remains with the practitioner.

Best practices include:

• Maintaining medical records for billing and auditing purposes. If Magellan requests records for review, it is the responsibility of the practitioner to provide those records, not the facility.
• Ensuring you have policies and procedures in place for documentation and record retention.

Lack of compliance with documentation standards may result in:

• An audit/investigation initiated by Magellan SIU.

• Invalidation of payment due to billed services not being supported.
• Any overpayment identified will be referred to Magellan's Cost Containment department for recovery by refund check demand or future claims payment retractions in compliance with applicable contractual and regulatory requirements.
• Magellan completing required reporting to a customer health plan and/or relevant oversight agency.
• Placement of a subset of claims or all claims on a required pre-payment review.
• Termination from the Magellan Network.

For more information

• Review Magellan's policy on audits and investigations in Section 4 of Magellan's National Provider Network Handbook (PDF), including:
• Cooperating with Magellan's audits and investigations.
• What to expect during a fraud, waste and abuse (FWA) or overpayment audit or investigation. 

• Contact your Network representative with questions about your contractual obligations to supply medical records for review.

• If you have additional questions regarding our audit/investigation processes, contact the SIU via email (SIU@MagellanHealth.com) or via our hotline 1-800-755-0850 (you may remain anonymous).