4 years after services are furnished.

Transcription

1 RECORD TYPE RETENTION PERIOD AUTHORITY MEDICARE 1 42 U.S.C. 1395x (v)(1)(i) Contracts with Subcontractors Any contract between a provider and a subcontractor and between an organization related to the subcontractor entered into or renewed after December 5, 1980 for services, the cost or value of which is $10,000 or more over a 12-month period, including contracts for both goods and services in which the service component is worth $10,000 or more over a 12- month period. HHA Condition of Participation: Retention of Clinical Records Clinical records are retained for 5 years after the month the cost report to which the records apply is filed with the intermediary, unless State law stipulates a longer period of time. Policies provide for retention even if the HHA discontinues operations. If a patient is transferred to another health facility, a copy of the record or abstract is sent with the patient. 4 years after services are furnished. 5 years after the month the cost report to which the records apply is filed with the intermediary, unless State law stipulates a longer period of time. 42 C.F.R Requirement for access clause in contracts. 42 C.F.R Condition of Participation: Clinical Records. For Certified Home Health Agencies Reopening of a Provider Reimbursement Determination and Appeal Determination or Decision A determination of an intermediary, a reviewing entity, decision by a hearing officer or panel of hearing officers, a decision by the Provider Reimbursement Review Board (PRRB), or a decision of the Secretary, CMS Administrator, Deputy or reviewing official may be reopened. Any request to reopen must be made no later than 3 years after date of decision, i.e., the Notice of Program Reimbursement (NPR), or PRRB decision. Reopening Based on Fraud However, notwithstanding paragraph (a) of 42 C.F.R , an intermediary determination or hearing decision, a decision of the PRRB, or a decision of the Secretary shall be reopened and revised at any time if it is established that such determination or decision was procured by fraud or similar fault of any part to the determination or decision. Financial Data and Reports Providers must retain financial records and statistical data for proper determination of costs payable under the program. Essentially, the methods of determining costs payable under Medicare involve making use of data available from the institution s basis accounts, as usually maintained, to arrive at equitable and proper payment for services to beneficiaries. 3 years from the date of the notice of the intermediary or Provider Reimbursement Review Board hearing decision or from the date of notice of the intermediary determination (except as provided in paragraphs (b)(3) of this section). An intermediary determination or decisions can be reopened AT ANY TIME if fraud or similar fault is established. New providers must make available to its intermediary for examination... for stated purposes (see 42 C.F.R (c)); continuing provider must furnish such information to 42 C.F.R (a) Reopening an intermediary determination or reviewing entity decision. 42 C.F.R (b)(3) Reopening of a determination procured by fraud. 42 C.F.R (a) (d) Financial Data and Reports 1 The regulations still refer to intermediary. However, CMS now uses the term Medicare Administrative Contractor (MAC) to include both intermediaries and carriers.

2 Recordkeeping Requirements Providers must retain documents to assure proper payment by the Medicare program. The document must include: information about related parties in order to identify parties responsible for submitting cost reports and to determine correct amount of Medicare payments and overpayments; The documents must include: records pertaining to (1) provider ownership, organization and operation; (2) fiscal, medical, and other record-keeping systems; (3) federal income tax status; (4) asset acquisition, lease, sale or other action; (5) franchise or management arrangements; (6) patient service charge schedules; (7) costs of operation; (8) amounts of income received by source and purpose, and (9) flow of funds and working capital; and copies of patient service charge schedules. Suspension If a fiscal intermediary determines that a health care entity does not maintain adequate records for the determination of reasonable cost under the Medicare program, Medicare payments will be suspended until the intermediary is assured that adequate records are maintained. DMEPOS Providers who furnish DMEPOS, home health, laboratory, imaging or specialist services must maintain ordering and referring documentation received from physicians and eligible nonphysician practitioners, including the referring physician or non-physician practitioner s NPI number. Physicians and nonphysician practitioners are also required to maintain written ordering and referring documentation. Failure to comply is a basis for CMS revocation of the Provider s Medicare enrollment and billing privileges. Medicare Advantage Managed Care Contracts Books and records pertaining to managed care contract be kept for 10 years from the end of the calendar year in which expiration or termination of the managed care contract occurs, or from completion of any audit or investigation, whichever is greater, unless CMS determines a longer time period. Books and records includes contracts, and subcontracts, documents, papers, medical records, Patient care documentation, personnel records, and any other information relating to provision of services under managed care contract. intermediary as may be necessary (see 42 C.F.R (d)). 7 years from date of service. Recommend at least 10 years from end of managed care contract. 42 C.F.R (d) Continuing Provider Recordkeeping Requirements 42 C.F.R (e) Suspension of Program Payments to Providers 42 C.F.R (f); Additional Provider and Supplier Requirements for enrolling and maintaining active enrollment status in Medicare (provider revocation detailed in 42 C.F.R (a)(10)) 42 C.F.R (e)(4), h, (i)(2)(i), and (i)(4)(v) Managed Care Contract

3 Medicaid Records and Claims Provider enrolled in the Medical Assistance Program must maintain contemporaneous records demonstrating the right to receive payment. Such records must be maintained for a period of six years from the date of care, service, or supplies were furnished, and must contain the nature and extent of furnished services and all information regarding submitted claims for payment. Cost-Based Provider All fiscal and statistical records and reports of providers which are used for the purpose of establishing rates of payment for Medicaid programs, and all underlying books, records, documentation and reports which form the basis of such fiscal and statistical records and reports (hereinafter referred to collectively as reports ). MEDICAID 42 U.S.C Recommend 7 years but regulation is 6 years. 6 years from date report filed or date required to be filed or 2 years from end of last calendar year in which provider s rate or fee was based on the filed report, whichever is later. For example, if 2003 cost report is filed in 2004, must keep report for 6 years, i.e., 2010, or If 2003 report is basis for 2005 final audited rates, two years from the end of 2005, which is Note the rate is provisional and not considered final for the 2 year period to commence, unless an audit of the rate by DOH has been performed and completed, or the period in which to conduct such audit has expired. The DOH has 6 years from date report is filed to audit. Therefore, recommend keeping records for 6 years from year of filing report. 18 N.Y.C.R.R (a) Duties of the Provider 18 N.Y.C.R.R (a)(2) Audit and Record Retention: Cost-based Provider. Fee for Service Providers Providers not paid by Medicaid approved rates or fees based on provider s allowable cost of operation, but are paid by Medicaid established rates, fees, and schedules must keep contemporaneous records which demonstrate nature and extent of services provided, medical Rule does not apply if there is fraud or the provider prevents or obstructs the audit. 6 years from the date of care, service or supplies were furnished or billed, whichever is later. 18 N.Y.C.R.R (a)(2) Audit and Record Retention: Cost-based Provider. 18 N.Y.C.R.R (b) Audit and Record Retention: Fee-for-service Providers.

4 necessity, i.e., prescription or fiscal order, and right to Medicaid reimbursement. Medicaid Managed Care Contracts MCO shall ensure medical records of enrollees be retained for six years after the date of service rendered to enrollees, and in the case of a minor, for three years after majority or six years after the date of the service, whichever is later. Medical Records A civil action under 3730 can be brought within 6 years after the violation or within 3 years after the U.S. Attorney knew or should have known of the violation, but not more than 10 years after the date of the violation. Due to a circuit split as to the exact date of service, or date of occurrence, there is a variation in the statute of limitations for the Act. Courts that hold that the date of occurrence is the submission of the claim will have a 6-year statute of limitation period. Courts that hold that the date of occurrence is the payment of the claim by the government will have a 7-year statute of limitation period. Clinical Records Each patient s clinical records shall be kept for six years after discharge from the agency. In the case of minors, records are to be kept for six years after discharge, or three years after minor reaches majority (18 years) whichever is longer. Employee Exposure and Medical Records Applies if an employee is exposed to toxic substances or harmful physical agents. The medical record for each employee shall be preserved and maintained for at least the duration of employment plus 30 years, except that the following types of records need not be retained for any specified period: (A) Health insurance claims records; (B) First aid records (not including medical histories); and (C) Medical records of employees who have worked for less than 1 year for the employer. Does not apply if any occupational safety had health standard provides a different retention period. Personnel Records 6 years after date of service but for minors, for three years after majority or six years after the date of the service, whichever is later. But recommend 10 years from date of service based on managed care contractual language. FALSE CLAIMS ACT 31 U.S.C. 3731(b) 6 years after date on which the violation of False Claim 3729 is committed, with a possible extension to 10 years. 10 NYCRR (n), Managed Care Contract NEW YORK STATE RULES FOR MEDICAL RECORDS 6 years after discharge. For minors, longer period of 6 years after discharge or 3 years after minor reaches majority, whichever is longer. Duration of employment plus 30 years 6 years from termination or resignation. 31 U.S.C. 3731(b) False Claims Procedures 10 N.Y.C.R.R (c) Clinical Records for certified home health agencies, long term home health care programs and AIDS Programs 29 C.F.R (d)(1)(i) Access to employee exposure and medical records 10 N.Y.C.R.R (a)(3)(iii) Records and Reports for certified home health agencies, long term home health care programs and AIDS Programs

5 Personnel Records (Home Care Worker Wage Parity) For workers where the Home Car Wage Parity Act applies, on an annual basis, CHHAs, LTHHCPs and MCOs must provide the Commissioner of the Department of Health written certification that all services provided are in full compliance with the terms of the Home Care Worker Wage Parity Law; the certification must include collective bargaining agreement (CBA) status and identification of the entities the CBAs are with. For organizations that elect to contract with licensed home care services agencies or other third parties, the CHHA, LTHHCP, or MCO must obtain a written certification that attests that the contracted entity is in compliance with this provision. These certifications must include all information necessary to verify compliance and that such information has been submitted to the CHHA, LTHHCP or MCO at least quarterly by the contracted entity. All providers must maintain records of compliance for at least 10 years and such records are to be made available to the Department upon request. Reports of Occupational Injuries and Illnesses (OSHA 300 Log, the privacy case list, if one exists, the annual summary, and the OSHA 301 Incident Report forms) 10 years N Y Pub. Health Law 3614-c, DHCBS Subject: Home Care Worker Wage Parity, August 22, years following the end of the year that these records cover 29 C.F.R Retention and Updating.