Physicians Don't Have to Specify Scientific Evidence in Chart, Expert Says

Hospitals should be on the lookout for possible claim denials that refer to physicians failing to specify in the patient’s chart the journal articles or other scientific evidence that informed their clinical decision-making. That goes against CMS policy and is grounds for appeal, an expert said.

At least one payer has instructed hospitals to only include in their appeals of claim denials the literature citations that had been considered by the treating physician, according to an excerpt of a letter from a Medicaid third-party auditor to a hospital that was posted to a group email list.

But physicians don’t document that way, said Denise Wilson, senior vice president of Intersect Healthcare + AppealMasters in Towson, Maryland. For example, they wouldn’t write notes that attribute their admission of a cardiac patient to a publication of the American College of Cardiology. Physician decisions are based on training and experience, and as long as appeal writers can support the physician’s decision based on standards of care that are consistent with the American College of Cardiology, “the hospital should get paid,” said Wilson, president of the Association for Healthcare Denial and Appeal Management.

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