Increase in Pneumonia and Pertussis Infections

via VDH

Dear Colleague:

This letter provides updates on increases in pneumonia and pertussis in Virginia.

Increase in Pneumonia Among Children

Since September 2024, the Virginia Department of Health (VDH) has observed a significant rise in emergency department and urgent care visits involving diagnosed pneumonia. During the week of November 10-16, 2024, there were 2,029 emergency department and urgent care visits with diagnosed pneumonia among children aged 0-17 years. This is more than triple the weekly peak observed in the past two years. There are also increases in visits among adults aged 18-64 years. In addition to this upward trend, numerous K-12 schools have reported clusters of students with pneumonia and unspecified respiratory illness. Laboratory testing has identified a variety of pathogens, primarily rhinoviruses/enteroviruses as well as Mycoplasma pneumoniae.

Rhinovirus infections are the most frequent cause of the common cold. Rhinovirus infections can exacerbate chronic respiratory diseases like asthma and chronic obstructive pulmonary disease (COPD). Enteroviruses have a broad spectrum of clinical presentations that can range from mild upper respiratory symptoms to more severe. It is uncommon for these viruses to cause pneumonia, so additional testing is being performed to type and analyze infecting viruses.

M. pneumoniae infections are generally mild and mostly present as a chest cold but may also present as pneumonia. Symptom onset is typically gradual and can include fever, cough, and sore throat. The Centers for Disease Control and Prevention (CDC) recently released a bulletin about a national increase in M. pneumoniae infections, especially in children 2-4 years of age. This differs from previous years in which most infections were observed among school-aged children and adolescents.

Providers are encouraged to:

  • Promote routine and seasonal immunizations and other healthy respiratory habits (e.g., staying home when sick, covering coughs and sneezes, frequently washing hands) to help prevent respiratory infections that can lead to pneumonia.
  • Consider enterovirus, rhinovirus, and pneumoniae as possible causes of infection among children with community-acquired pneumonia.
  • When possible, perform full respiratory panel testing if pneumonia is suspected, especially among hospitalized children, to ensure appropriate treatment is administered.
  • Consider swabbing both the throat and nasopharynx to improve the likelihood of pathogen detection in respiratory swab specimens.
  • Be aware of treatment recommendations for pneumoniae infections and promote the judicious use of antibiotics by prescribing only when indicated by clinical and/or laboratory evidence.

For more information, please see CDC’s Pneumonia and M. pneumoniae webpages.

Increase in Pertussis

VDH continues to respond to an increase in cases of pertussis (whooping cough). This trend was first reported in August and is linked to outbreaks in group settings, including universities, schools, religious communities, and childcare settings.

Providers are encouraged to:

  • Ensure all patients are up to date on DTaP and Tdap vaccination.
  • Maintain a heightened index of suspicion for pertussis in patients presenting with respiratory illness, especially with prolonged cough.
  • Obtain a nasopharyngeal (NP) swab or aspirate for testing of suspected cases. Contact your local health department to request pertussis testing at Virginia’s state public health laboratory.
  • Ensure appropriate antibiotic treatment (e.g., azithromycin, erythromycin) for pertussis patients. Please note that ciprofloxacin and doxycycline are not recommended for pertussis treatment.
  • Ensure timely receipt of post-exposure prophylaxis (PEP) antibiotics for contacts meeting high-risk criteria. People who refuse PEP should be excluded from high-risk settings for 21 days.

Thank you again for your continued partnership in keeping Virginians safe from respiratory illnesses. Although influenza, COVID-19 and RSV activity is currently stable in Virginia, we expect these trends to increase in the coming weeks. Please visit the VDH website for current public health guidance on respiratory diseases in Virginia and other information.   

Sincerely,

Karen Shelton, MD
State Health Commissioner

SafeHaven Launches Podcast for Healthcare Professionals Focused on Solving Practice Challenges

RICHMOND, VA – SafeHaven®, a program of the Medical Society of Virginia (MSV), announce the launch of a podcast for clinicians focused on solving the challenges of today’s medical practice environment. Titled “JoyMed,” and hosted by MSV CEO and Executive Vice President Melina Davis, the podcast is intended to help medical leaders share experiences and solutions while exploring ways to bring joy back into everyday life and the practice of medicine.

“In today’s environment, stress and burnout are very real issues for healthcare professionals of all kinds — from physicians and nurses to pharmacists and even students,” says Davis. “This podcast is an extension of our SafeHaven program, which provides confidential support to healthcare professionals, addressing career fatigue and other mental health challenges. It’s critical that we encourage healthcare professionals at all levels to seek the help they need, and provide the tools and resources to create a culture of care and support, so they can reclaim their work-life balance and joy at home and in the work they do.” 

“It’s important for medical professionals to take be cared for so they can care for others”

Davis continues. “By bringing important issues to light, and encouraging honest and meaningful dialogue that focuses on solutions, the JoyMed podcast is one more way we’re helping healthcare professionals reinforce and rediscover their purposeand joy, and ensuring those who care for us are cared for as well.” 

The JoyMed podcast will delve deeper into the unique challenges faced by healthcare professionals, explore strategies for resilience, and highlight the support systems available to them. Each podcast episode will feature expert insights, personal narratives, and practical tools to help foster a healthier and more supportive environment for our healthcare heroes.

The podcast’s first three episodes were released on Spotify and Apple Podcasts on October 17. Episode 1 highlights MSV’s SafeHaven program and its origin. Episode 2 features a PA’s experience with burnout. Episode 3 takes a look at the future of medicine from the perspective of both a medical and physician assistant student.  

Additional JoyMed episodes will release on a monthly schedule.  

About SafeHaven

SafeHaven was founded by the Medical Society of Virginia (MSV) after recognizing a greater need to provide clinicians the support to stay well and prevent burnout. SafeHaven ensures clinicians can seek support for burnout, career fatigue, and mental health reasons without the fear of undue repercussions to their medical license. Protections vary by state. 

About the Medical Society of Virginia

The Medical Society of Virginia is a professional association with 10,000 members. The MSV is the only association representing all medical doctors, doctors of osteopathy and PAs, regardless of specialty or type of practice setting, in Virginia. Dedicated to Virginia’s physicians, PAs, and their patients, the MSV provides administrative, membership, and legislative services to its members, as well as serving as the liaison between local, national, and specialty medical organizations. 

The 2025 Medicare Physician Payment Schedule Final Rule

On Nov. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Revisions to Payment Policies under the Medicare Physician Payment Schedule (PFS) and Other Changes to Part B Payment and Coverage Policies final rule. The rule includes proposals related to Medicare physician payment and the Quality Payment Program (QPP).

These policies will take effect on January 1, 2025, unless otherwise noted.

The AMA Final Rule Summary detailing the payment updates and proposals is available here.

Are Physician Loan Repayment Programs Good for Primary Care?

Physician pay is decreasing while the cost of a medical education continues to increase. What’s to be done? Can physician loan repayment programs make a difference? Specifically, are physician loan repayment programs good for primary care? Considering there is a projected shortage of 68,020 full-time primary care physicians by 2036, improvements to the primary care workforce are critical to our nation’s healthcare delivery. 

Let’s take a closer look. 

Medical Education Costs 

Becoming a doctor is an investment, and 70 percent of medical students borrow money to attend medical school. According to the Association of American Medical Colleges (AAMC), in 2023 the average medical school debt was more than $200,000 — which with interest can balloon to $300,000 over the life of the loan. 

Four years of medical school costs between $268,476 for public medical school and $363,836 for private medical schools, according to the AAMC. And that doesn’t include costs like living expenses, textbooks, or supplies. It also doesn’t include the cost of an undergraduate education.  

Undergraduate tuition is going up, and has been for the last two decades. In 2023-24, the average cost of attending a 4-year, in-state public college was $28,840, compared to $60,420 at a private institution, with out-of-state public colleges costing 62 percent to more than 100 percent more than in-state. The average cost of an undergraduate education increased for 2024-25 academic year for both public and private schools, according to a new report from U.S. News. Once again, that cost doesn’t factor in room, board, and textbooks, which can add thousands more to the bill. It’s worth noting that grants and other aid can reduce the costs of an undergraduate education. 

Bottom line: Despite incurring substantial costs — and debt — to become a physician, the upward trajectory for education costs unfortunately isn’t matched by physician pay. 

Physician Pay

After several years of modest or declining growth, average pay for physicians increased by 5.9 percent in 2023, according to Doximity’s “2024 Physician Compensation Report” published this past May. At first glance this appears to be positive step forward, especially considering 2022 saw a drop of 2.4 percent. 

Unfortunately inflationary pressures continue to negatively impact physicians’ real income. Plus Medicare physician payment has decreased 22 percent since 2001. And in addition to the Centers for Medicare and Medicaid Services (CMS) cutting overall physician pay 1.25 percent in 2024, a proposed new CMS payment rule could see Medicare reimbursement fall by an average of 2.9 percent next year. 

Bottom line: Inflation plus declining reimbursements combine to create contracting physician pay, with primary care physicians already making significantly less than specialists — and nearly $100,000 less per year than the average for all physicians. 

Physician Loan Repayment Programs

Increasing debt and declining physician pay combine to create and exacerbate risks — like the physician shortage, specialty gaps, and physician stress and burnout, which comes from overwork, among other factors. The ultimate loser is patient care. 

Can physician loan repayment programs make a difference? Specifically, are physician loan repayment programs good for primary care? The answer to both is “yes.” They can certainly make an impact on a physician’s debt — which then has an impact on decisions like specialty as well as where a physician decides to practice. 

Offered as a recruiting incentive, educational loan repayment is an attractive benefit. In exchange for an employment commitment, a recruiting hospital or other facility will pay a physician’s medical loans. An April article by the American Medical Association (AMA) cites 2023 stats from recruiting firm AMN Healthcare’s Physician Solutions division indicating 18 percent of searches included loan repayment benefits. The average amount in 2022-23 was $98,665, and most applicants were required to stay in their position for 3 years or more. The range of incentive amounts offered varied from $10,000 to $400,000. 

Other opportunities for physician loan repayment also are available — and specifically for primary care. Due to the exceptional need for primary care physicians, loan forgiveness programs are more widely available for these fields than other specialties. 

Through the Health Resources & Services Administration (HRSA), the National Health Service Corps (NHSC) offers loan repayment to licensed primary care physicians in exchange for serving at least 2 years at an NHSC-approved site in a Health Professional Shortage Area (HPSA). HPSAs can be defined by geography, population, or facility type, like private medical facilities, correctional facilities, or Federally Qualified Health Centers (FQHCs). In fact, this April the HRSA increased loan repayment amounts by 50 percent for primary care providers who commit to practicing in high-need and rural areas. 

Public Service Loan Forgiveness (PSLF) programs are also an option. Physicians must complete full-time public service employment by a 501(c)3 tax-exempt nonprofit or public institution, and includes working in areas that are underserved or have a high need for medical professionals. In this program, borrowers must make monthly payments for 10 years during PSLF-qualified work, after which the federal government will forgive their remaining debt. 

Military programs are another option. Military branches offer tuition assistance for students who are service members, but even doctors who have already graduated and are practicing can enroll in military service to get student loan assistance. Programs vary by branch. 

For state programs, the Association of American Medical Colleges (AAMC) maintains a searchable database of loan repayment and other programs for students and residents. 

Although loan repayment programs are obviously a benefit more geared toward younger physicians, as established physicians have a higher likelihood of having paid off their debt and have already selected their area of specialty, they can be a terrific way to reduce large portions of debt early in a physician’s career. They can also encourage physicians to specialize in high-need areas, as well as serve high-need populations — specifically in primary care. 

2024 SafeHaven Impact Report

SafeHaven is growing and expanding – and our providers report that they’re seeing the benefits.

Get the 2024 SafeHaven Impact Report to learn more about the SafeHaven Movement and history, the program’s expansion, and the latest data on participant engagement and outcomes.

Disruption in Production of Intravenous (IV) Fluid due to Impacts from Hurricane Helene

Dear Colleague:

This letter provides an update to the Clinician Letter that the Virginia Department of Health (VDH) sent on October 21, 2024, regarding the disruption in production of IV solutions as a result of Hurricane Helene on the Baxter International Inc. North Cove manufacturing facility in Marion, North Carolina.

Per an update from Baxter on October 28, 2024, the manufacturer has received Food and Drug Administration (FDA) authorization to extend the use dates of 50+ IV and irrigation codes to provide up to an additional 12 months of expiry. Products now have a 24-month expiry period from the date of the manufacture. This extension only applies to products manufactured prior to the end of September 2024. Details have been communicated directly to customers per the manufacturer.  Please continue to monitor manufacturer notices or guidance related to expiration dates of products and imported solutions at your facility.

Baxter has information regarding the Peritoneal Dialysis (PD) allocations and support in the above update. For additional peritoneal dialysis questions or support in Virginia, please contact Quality Insights Renal Network at [email protected], [email protected].

Conservative strategies and measures remain important and effective to mitigate the potential impacts of manufacturing disruption. VDH is requesting all health care providers continue to implement conservation measures and guidance from  FDA for  temporary policies for compounding parenteral drug product.  

The Centers for Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) on October 12, 2024 with recommendations for healthcare providers, pharmacists, and healthcare facility administrators in healthcare facilities.  Current data indicates some supply stabilization with the use of conservation strategies.

VDH continues to work closely with the Virginia Hospital & Healthcare Association (VHHA), Virginia Health Care Association (VHCA), Quality Insights Renal Network, Virginia’s EMS Councils, and other health care organizations, alongside our federal partners, to closely monitor this situation and will continue to provide updates as soon as available.

IV Fluid Resources and Updates

https://www.baxter.com/baxter-newsroom/hurricane-helene-updates

https://meded.baxter.com/hurricane-helene-clinical-resources

https://emergency.cdc.gov/han/2024/han00518.asp

https://www.fda.gov/drugs/updates-2024-hurricane-season/hurricane-helene-baxters-manufacturing-recovery-north-carolina?mkt_tok=MzgxLU5CQi01MjUAAAGWWYbABpHEnn9cG8gVJV_nVutY1jYK7dRw9v2X-ImJsNVprSSy5oCwzp-4H3-WFpHZ9ofOHIFIEOqR7H8dQyQx7EZUNfVH6HOAIvVBs-yeVdZ9Qg

https://www.fda.gov/news-events/press-announcements/fda-roundup-october-11-2024https://www.vdh.virginia.gov/news/hurricane-helene-post-storm-response/#Clinician

https://www.hhs.gov/about/news/2024/10/24/statement-secretary-xavier-becerra-iv-fluid-increase.html

Fact Sheet: HHS Continues Taking Action to Increase Access and Supply of IV Fluids Following Hurricane Helene | HHS.gov

https://www.vdh.virginia.gov/news/hurricane-helene-post-storm-response/#Clinician

Dialysis Management and Conservation:
https://www.baxter.com/sites/g/files/ebysai3896/files/2024-10/10-1_RenalMedical%20Information%20Letter.pdf

List of Parenteral Drug Products in Shortage:
Hurricane Helene: Baxter’s manufacturing recovery in North Carolina | FDA

Products authorized for temporary importation:
https://meded.baxter.com/sites/g/files/ebysai4096/files/2024-10/Temporary%20Importation%20Report%2010.24.24_Final.pdf

Expiration Dating Extensions:
https://meded.baxter.com/sites/g/files/ebysai4096/files/2024-10/ExtendedExpDatesIVSolutions%20v2.pdf

Additional Resources:   

https://www.ashp.org/drug-shortages/shortage-resources/publications/fluid-shortages-suggestions-for-management-and-conservation?loginreturnUrl=SSOCheckOnly

https://www.fda.gov/regulatory-information/search-fda-guidance-documents/temporary-policies-compounding-certain-parenteral-drug-products

Sincerely,
Karen Shelton, MD
State Health Commissioner

DBHDS, MSV Launch Program to Help Physicians Better Assist Adults Dealing with Substance Use Disorders

RICHMOND, Va., October 30, 2024 – The Virginia Department of Behavioral Health and Developmental Services (DBHDS) and Medical Society of Virginia (MSV) are launching a resource aimed to help adults struggling with substance use disorders (SUDs).

The Adult Psychiatric Access Line (APAL), a program of HealthHaven, is a statewide care navigation and consultation program that provides adults affected by SUDs access to specialized behavioral health services. The initiative equips healthcare providers – specifically primary care and emergency clinicians – with tools and consultation with addiction specialists to diagnose, prescribe and assist patients seeking care. The first APAL hub, housed at the Master Center for Addiction Medicine, is now active and taking calls from PCPs across the commonwealth.

“For over 10 years, the leading cause of unnatural death in Virginia has been drug overdoses, and this trend is even worse by the dangers of opioids and fentanyl,” DBHDS Commissioner Nelson Smith said. “We want to make sure healthcare providers know how to effectively help a patient struggling with substance use disorders. APAL builds on the big successes of the Virginia Mental Health Access Program (VMAP) for children and will ensure that primary care providers have the resources they need to help their patients recover from substance use disorders.”

APAL features three main components.

  • Provider education on screening, diagnosis and management of SUDs
  • Access to phone consultations via regional hubs with access to professional support from addiction medicine specialists, psychiatrists, psychologists and/or social workers 
  • Care navigation assistance to identify regional care and services 

Primary care providers (PCP) calling HealthHaven’s APAL program will be directed to a regional hub operator to provide intake information to a Licensed Psychological Practitioner (LPP) or care navigation team member. Within 30 minutes, an addiction medicine consult team will contact the PCP for support, and if needed, the PCP then will be connected to a care navigation team to work directly with the patient to assess next steps based on the region and services available.  

“Since 2016, Master Center has delivered addiction treatment to 10,000 Virginians with substance use disorder. We are prepared to equip primary care physicians with the tools to address this critical public health crisis,” said Anna McKean, CEO of the Master Center for Addiction Medicine. “We are proud of our work with MSV and DBHDS in the development of this life-saving initiative.” 

“Substance use in Virginia mirrors what we’re seeing nationally: The problem isn’t going away,” said Melina Davis, CEO and EVP of the Medical Society of Virginia. “VMAP is helping to better equip our primary care providers seeing pediatric patients with tangible ways to make a difference. With all of Virginia’s localities designated as mental health professional shortage areas, APAL will bridge the access gap across the state for PCPs seeing adults with substance use disorder.” 

Both APAL and VMAP are important efforts in Virginia Gov. Glenn Youngkin’s Right Help, Right Now initiative to reform Virginia’s behavioral health system, support individuals in crisis and support Virginians before, during and after a behavioral health crisis occurs.  

* * * 

Adult Psychiatric Access Line (APAL), a Program of HealthHaven 

APAL is a statewide consult and care navigation program designed for adults struggling with substance use disorders to access specialized behavioral health services and prepare primary care and emergency clinicians to support patients’ behavioral health needs through trainings and education.  

Virginia Department of Behavioral Health and Developmental Services

The Department of Behavioral Health and Developmental Services (DBHDS) seeks to promote dignity, choice, recovery and the highest possible level of participation in work, relationships and all aspects of community life for individuals with mental illness, developmental disabilities or substance-use disorders. DBHDS operates 12 state facilities and partners with 40 locally-run community services boards and hundreds of private providers statewide. For more information, please visit www.dbhds.virginia.gov, and find DBHDS on Facebook, LinkedIn, Instagram or YouTube. 

Medical Society of Virginia 

The Medical Society of Virginia strives to advance high-quality care and make Virginia the best place to practice medicine and receive care. We provide relevant insurance coverage options and benefits, and the administrative, membership, and legislative services to the over 30,000 physicians and PAs in the Commonwealth so they can focus on what they love, caring for patients. 

Medical Society of Virginia Insurance Agency Expands to Serve Dental Professionals

Introducing InsureHaven: A New Brand Focused on Dental Practice Insurance

Richmond, VA – [October 1, 2024] – The Medical Society of Virginia Insurance Agency (MSVIA) is thrilled to announce a new chapter in its mission to support healthcare professionals across Virginia. MSVIA is now extending its services to dental practices under the newly launched InsureHaven brand, which is owned by MSVIA. This strategic expansion marks a significant milestone, bringing specialized insurance solutions to Virginia’s dental community.

“As we’ve listened to healthcare professionals across the state, it became clear that dental practitioners, like physicians, seek an insurance provider who truly understands their unique needs,” said Melina Davis, CEO of MSVIA.

“With over 25 years of experience serving the medical community, we are excited to expand our reach and welcome dentists into our growing network.”

The launch of InsureHaven, a new brand under MSVIA, reflects MSVIA’s commitment to offering comprehensive, tailored insurance products that address the specific risks and challenges dental professionals face. The new brand highlights a deep understanding of the dental profession, delivering solutions that offer peace of mind and empower dental practices to thrive.

“At MSVIA, our dedication to supporting all healthcare professionals is at the core of every decision we make,” Davis added. “We’ve worked closely with dental practitioners to develop insurance offerings that not only meet but exceed their expectations. InsureHaven is designed to provide unparalleled protection and support for Virginia’s dental community.”

This expansion builds on MSVIA’s longstanding tradition of serving the healthcare sector with excellence. By extending insurance solutions to dentists, MSVIA is reaffirming its role as a trusted partner for healthcare professionals statewide.

Dental professionals are encouraged to explore InsureHaven, MSVIA’s new brand offering tailored solutions that ensure their practices are protected. For more information, please visit www.MSVIA.org or contact our dedicated customer service team.

About the Medical Society of Virginia Insurance Agency
The Medical Society of Virginia Insurance Agency (MSVIA) is a full-service independent insurance agency specializing in property and casualty commercial insurance. With over 25 years of experience, MSVIA proudly serves the insurance needs of Virginia’s healthcare community, including physicians and dental offices. InsureHaven, owned by MSVIA, represents MSVIA’s latest initiative to support dental practices with comprehensive insurance solutions.

Update on Disruption in Production of Intravenous (IV) Fluid Due to Impacts from Hurricane Helene

via VDH

Dear Colleague:

Last week, the Baxter International Inc. North Cove Facility in Marion, NC was impacted by Hurricane Helene. Baxter is a major U.S. manufacturer of IV solutions, accounting for approximately 60% of domestic production. Baxter has announced reduced supply of intravenous and peritoneal dialysis (PD) solutions due to the damage of its manufacturing plants from hurricane Helene.

In letters to its clients, Baxter indicates it has implemented reduced supply allocations on a number of products. We understand that allocation amounts range from 40-50 percent from some of the more common IV solution products. Therefore, healthcare providers are expected to receive fewer IV products from Baxter than they are traditionally accustomed to receiving in orders placed based on consumption of these resources. For the most current updates on the product availability, please contact the manufacturer directly.

As of today, FDA has not declared any new shortages related to items produced at the North Cove facility. Baxter reports that they are taking additional steps to manage inventory of their North Cove production to assure equitable access. We understand that the FDA is also working with Baxter’s additional facilities to increase supply and reduce the risk of new shortages until Baxter can resume manufacturing the impacted products.

IV Solution Temporary Conservation Measures

Virginia Department of Health (VDH) is requesting all health care providers to immediately implement temporary conservation measures to mitigate the potential impacts of this manufacturing disruption. This is a rapidly evolving situation, and this information is subject to change. Virginia Department of Health is working closely with the Virginia Hospital & Healthcare Association (VHHA), and coordinating with Administration for Strategic Preparedness and Response (ASPR), Quality Insights Renal Network, Virginia’s EMS Councils, and other health care organizations to closely monitor this situation and we will continue to provide updates as soon as available.

Resources

Dialysis Management and Conservation

List of Impacted Products

Small- and Large-Volume Fluid Shortages – Suggestions for Management and Conservation

Patient safety nonprofit releases guidance for navigating medical supply chain disruptions caused by Hurricane Helene

Sincerely,

Karen Shelton, MD
State Health Commissioner

Healthcare Provider and Health Systems Audits: Responding to an Auditor’s Request for Records


The Reimbursement Team at Hancock, Daniel & Johnson, P.C. provides legal representation to providers and health systems embroiled in disputes with government and private payors.

In the event of audits, our clients often come to us immediately to assist in responding to record requests, but it is sometimes appropriate for a provider to handle the initial production internally.

In those cases, we provide the following tips to avoid common mistakes in responding to an auditor’s request for records and to maximize the opportunity for good audit results:

  1. Start early to respond to a request for medical records. As soon as a notice of an audit and request for documents is received, develop a plan for responding. The process is time-consuming and could require multiple reviews of medical records.
  2. Identify who is conducting the audit and note when the audit is being conducted by a governmental regulatory body that typically reviews for fraud, waste, and abuse. In those situations, it may be best for Hancock Daniel’s Reimbursement Team to help navigate the document production.
  3. Determine, if possible, what issue is under audit. Is it medical necessity, E&M code leveling, or something else? This will help determine whether to produce more records than those requested. For example, if the audit involves a medical necessity review, a clinician should be involved in identifying which records to submit because proving medical necessity may require a review of records before the date of service at issue and not just the office note from that date.
  4. Make note of the deadline for submitting the records. If necessary, request an extension and be sure to get the extension in writing. Do not miss the deadline for submitting the records. Missing deadlines can result in procedural defaults and force the provider to defend an overpayment and recoupment request. It can also unnecessarily force the provider into the appeals process, which can be expensive and time consuming.
  5. Collect the records and do not send the request to a medical record vendor. Responding to an auditor’s medical records request is different than responding to a request made for other purposes and it should not be put in the hands of a record vendor.
  6. Once the records are collected, ensure they are complete. One of the most common errors providers make is sending incomplete records. This can have devastating consequences because the auditor may conclude that the records do not exist and/or the care was not provided and refer the matter to regulatory bodies to consider whether there is fraud, waste, and abuse.
  7. Do not include extraneous or irrelevant records. Do not send the entire electronic medical record unless it is requested. Sending unnecessary records such as nursing flowsheets and administrative forms can complicate the review process and potentially raise questions about compliance practices.
  8. Be sure the records are legible. The goal is to make it easy for the auditor to find the information in the records that justifies the claim paid for that service. Do not submit a printed and scanned copy of the records because they are often illegible, and the auditor will have a more difficult time finding the necessary information.
  9. Organize the records. Do not send a pile of unorganized records without any context or explanation. This can make the audit process needlessly challenging. Organize and label records in a logical manner that demonstrates the office is managed well, has a commitment to regulatory compliance, and can be trusted to provide accurate claims for payment.
  10. Review the records for any potential issues that the auditor may find. Identify any errors (incorrect patient or date of service) or omissions (missing signatures). Never modify or alter records in response to audit requests. It is imperative to maintain the integrity of the medical records and produce them in the original, unaltered state. Any attempts to manipulate, falsify, or add documentation can create exposure to severe legal consequences. While records cannot be altered, any issues can be identified and explained to the auditor in the cover letter to mitigate potential concerns. This review can also reveal risk exposure and provide information about whether to engage legal counsel before submitting the records.
  11. Draft a cover letter to send with the record production. Include sufficient information that identifies the date of the records request, the date the records are submitted, and a description of what records are being submitted. In the cover letter, send a message of transparency to the auditor. Avoid any defensiveness or indication that you do not want the auditor to see the medical records. They have a right to see the records that support your claims, either through regulations or by contract.
  12. IMPORTANT. Keep a copy of the cover letter and a complete copy of the exact records produced in case an appeal is necessary in the future.
  13. When the audit results are received, review them and if an overpayment is noted, immediately contact a member of Hancock Daniel’s Reimbursement Team to help determine whether an appeal would be appropriate.

Click here for a full PDF version of this advisory.

The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson, P.C., is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson, P.C. be liable for any direct, indirect, or consequential damages resulting from the use of this material.