In 2009 many healthcare practices had to payback millions of dollars to insurance companies. Why? Insurance companies performed audits and felt that services were not medically necessary, documentation did not support billing, lack of patient progress- to name a few. The number of providers audited will continue to grow every year and payback dollars to insurance companies will also multiply. While some cases are fraud and abuse, most finding are because of lack of documentation and simply an oversight on part of provider. But as they say, "If its not documented, then it wasn't done."

I highly recommend taking a look at the APTA website as it has many resources on documentation requirments.

Top 10 Payer Complaints about Documentation

(Reasons for Denials)

1. Poor legibility.

2. Incomplete documentation.

3. No documentation for date of service.

4. Abbreviations – too many, cannot understand.

5. Documentation does not support the billing (coding).

6. Does not demonstrate skilled care.

7. Does not support medical necessity.

8. Does not demonstrate progress.

9. Repetitious daily notes showing no change in patient status.

10. Interventions with no clarification of time, frequency, duration.