Reference no: EM133170129

Medical Record Audit

You are the Release of Information Supervisor in the HIM Department. In this role, you are responsible for assuring appropriate disclosures of health information. This includes responding to medical record audit requests for Government oversight agencies.  You've received a medical record request from CMS, requesting the entire medical record for several Medicare patients. The purpose of this request is to validate the medical necessity for the care and services provided during the patient stay.

Following the procedure, after obtaining the requested medical records, you send the records over to the utilization review team, who is primarily responsible for coordinating patient treatment and services to maximize patient care. This team also reviews all medical records before being sent to an auditor for medical necessity review. This process helps assure that all required components are included in the medical record to support the medical necessity of the encounter.

Upon the utilization team's review, they find documentation in several progress notes inferring that the patient's actual condition didn't require the intensity of services that were provided. In other words, this documentation could invalidate the medical necessity of each visit and may result in the rejection of payment for each encounter. If discovered by the auditor, the hospital will lose a lot of money. The utilization review manager has asked you to omit these progress notes from your submission to CMS so that the information is not discovered by the agency. She has assured you that "no one has to know about this and it will save the hospital a lot of trouble later on".   

What will you choose to do in this situation?

1. Identify whether there is an ethical concern, and if so, what the ethical concern is.
2. Determine how the scenario should be handled. For instance, if you were the leader in the selected situation, how would you manage the issue?
3. Recommend course(s) of action to be taken.