As the healthcare industry has evolved into a quality-based reimbursement model, it certainly seems like reviews of patient charts are full-steam ahead.  The review process is just one more thing you have to do, all while shifting staff focus away from other important tasks.

The hassle and headache

When review season rolls around, healthcare practices just like yours let out a sigh of exasperation.  Reviews take your resources’ time negotiating payer contracts, determining if your practice is legally obligated to participate in the review, managing the review process and more.  Some auditors are insistent on coming onsite, taking up your space, paper, toner and time setting up EHR permissions!  Not to mention, no one wants to spend their time babysitting a reviewer to ensure they only access the appropriate files.  When auditors do not come on site, your staff is often forced to conduct the reviews, pulling and auditing the appropriate files with quick turnaround times, taking time away from other necessary tasks.

Both types of reviews are subject to a possible unauthorized disclosure, and no one likes dealing with a HIPAA incident.  Practices around the country agree – reviews are a time and resource hassle, as well as a compliance and cost headache.

What’s the difference between reviews and audits?

While you may be familiar with the review process, payers are often asking you for charts and have historically used the word “audit” when making these requests. Typically, payers will send over chart pull requests with the label “chart review,” “chart audit,” “patient pull list” and the like. The payer needs the charts in order to audit a provider, practice or diagnosis code, and while this task may have been called an “audit,” your HIM department is not responsible for actually auditing the content in the chart.

Are reviews mandatory?

Not all reviews are mandatory! Make sure to review your payor contracts to see if the review is mandatory or optional.

What do I need to do with a review?

When the need or desire to do a review is confirmed, ensure you establish the parameters of the review, including patient names and the timeframe.  Then, negotiate the appropriate service fees with the requestor as appropriate for the audit.  Pull the appropriate charts, ensuring HIPAA compliance through auditing before release of the information, and submit per the parameters to the payer or requestor.  Finally, notate this disclosure as part of your organization’s Accounting of Disclosures since there was not an authorization in place for the records but it was subject to the Payment provision of HIPAA.

Why are reviews important?

Ultimately reviews can impact a provider’s contract negotiation with payers. The way healthcare organizations are reimbursed by commercial insurance is somewhat based on what the payers find in these audits and reviews. Accuracy = Money.

What challenges could I face with reviews?

While reviews often have a direct financial impact on a practice, that’s not all.  Reviews typically happen in seasons, which can pose a variety of challenges on healthcare organizations including…

  • Short straw: If you’re using members of your own staff to complete reviews, you may have had to promise the moon to the people who drew the short straw. These reviews are widely lamented by staff and often require some arm twisting and/or groveling, depending on your style. In addition to the wear and tear on the staff, it can also be costly because it often requires overtime hours to get the work done outside of the normal duties.
  • Seasonal staffing strife: Trying to find reliable, short-term staffing for reviews can be both expensive and time consuming. Instead of taking a current member of your staff away from their current patient care, some resort to getting temporary or seasonal employees, which means training and managing someone who is only there for a short time. This approach often results in a time sink and always come with a compliance risk.
  • Outside in: Whether it’s an auditor or a temp employee, having someone come in your office and work in your systems is intrusive. Navigating physical work spaces along with allowing someone you don’t know access to your EHR is a hassle for practice administrators. You not only have to make sure the auditors only have access to the information they need and restrict the rest of the PHI, you also have to continually monitor them while in the office.
  • Money pit: Whether reviews are in your contract for no payment or negotiable, there’s a strain on you and your staff. Processing the audits and sorting out the financial and contractual obligations takes extra time and know-how.


Ready to let go of the burden of reviews? ScanSTAT can help! When we take on your release of information, we can also handle any reviews and audits that come your way. So the only remaining question is… how will you use the time you save delegating the review process?  Reach out to us today to learn more about how ScanSTAT can help you with the review and audit process.