When a practice undergoes an audit, payers often request medical records for a small segment of patients to assess provider documentation for medical necessity. While there are common expectations among payers, each has its own guidelines, typically published on their websites. It is crucial for practices to review these guidelines at least once a year and adopt a standard for documentation.
Below is an example of guidelines we gathered from BCBS Horizon:
Conservative Care: Evidence of an adequate trial of conservative care over time is required.
🔹 Physical Therapy: Copies of therapy notes are required. The therapy should be of a duration that, according to industry standards, will demonstrate a therapeutic effect unless contraindicated.
🔹 Home Exercise Program (HEP): A reference that a member has been provided HEP instructions and/or continues HEP at home is not sufficient to support medical necessity. Specific documentation of HEP over time, including the impact on symptoms, must be presented.
🔹 Medication Therapy: Documentation must clearly capture the type of drug, dosage, frequency, and the response of symptoms to treatment over time.
At PainMed – PA, we conduct an annual review of these guidelines for our clients to keep the up to date.