Be Prepared

Health Folders

How to respond to a Medicare medical record request.

By Olajide Kolawole, PT, MS, PhD

In recent years, the Office of Inspector General, among other Medicare entities, has intensified review claims on physical therapists in private practice. As a practice owner, you must be aware of what to do when you open your mail and find a request for documentation. Providers who have a high percentage of patients who’ve exceeded the $3,700 threshold as of the end of 2017 may be targeted. However, there are other reasons why a request for documentation may be sent.

How do you prepare?

Regardless of which agency is requesting the information, make sure your policies and procedures clearly indicate how to address the request.

A request for documents usually comes in the mail. Therefore, designate someone in your office to bring any mail from Medicare to your attention immediately. Medicare usually gives enough time to respond to any inquiry.

When you receive a notice of a Medicare audit, bear in mind that the due date is not the last date on which you can mail the records but rather the date that the records must be at the auditor’s office. It is extremely important to respond in a complete and timely fashion. However, if you cannot make the deadline, request an extension.

One of the mistakes a medical practice can make when they receive a request for medical records from a payer such as Medicare is to quickly copy some records and throw them into an envelope. Review all the charts before sending them and follow the instructions in the letter. The instructions clearly state how the documents should be prepared. Medicare auditors usually list the types of information the auditor expects. You may wish to contact a consulting company for further assistance if necessary. Consider these steps when completing your Medicare audit request:

1 Before submitting any records to Medicare, make sure records are legible and for each date of service requested. In addition, make sure the documents are well organized so that auditors can easily find the pertinent records.

2 Any documentation that shows illegible handwriting should be accompanied by a transcribed copy. You should mention any transcribed document in the cover letter as well. Also remember to include a list of abbreviations used in your clinic because some Medicare auditors are not physical therapists.

3 In responding to the request, include a cover letter explaining that you are replying to their request. Make sure contact information is included for you or a designated person to be responsible for responding to follow-up. Include a summary addressing medical issues in your documentation or any other information you would like to bring attention to.

4 Check your plan of care (POC) for physician signature and date. In addition, make sure that your POC contains diagnosis, long-term goals, therapy frequency and duration. If you do not have a document requested, do not fabricate. Just explain why you do not have it. If your plan of care was not signed on time, include a delay certification.

5 Keep a copy of all documentation sent to Medicare and number the pages prior to sending. It is easier to appeal an audit when you and your advisors are sure what was sent.

6 The cover letter is not a substitute for the medical records but will assist a Medicare auditor who may not be experienced in a physical therapy practice area. Make sure that any such summary of the latter is clearly marked. Do not allow any room for confusion.

7 Use a mail carrier and request a return receipt to provide you with a record of delivery. If the record is submitted electronically, make sure you have the printout of the submission.

8 If there is any telephone communication with the Medicare auditor, you should follow up with a letter confirming the telephone conference.

9 Once the requested documentation is received, the provider will receive a response within 45 days. Any provider who wants to learn more about the decision that was rendered, or how they can avoid these types of audits in the future, can submit a request for a discussion and education period in writing. However, it must be submitted within 30 days of the date on the Review Results Letter.

Olajide Kolawole, PT, MS, PhD is the owner of Kebe Cares Physical Therapy. He can be reached at

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