John Falcetano (john.falcetano@brooksrehab.org) is Director Corporate Compliance at Brooks Health System in Jacksonville, FL.

A critical element of any effective compliance program is monitoring. As a service to our members, each month this column focuses on potential monitors for specific business lines or functions.

“A prior OIG review found that Medicare allowed $185 million in inappropriate outpatient mental health services” that were either not covered or were not adequately documented.^[1] Documentation is a critical element for providing quality patient care—in addition to a necessity for receiving proper reimbursement for furnished services. Medical records consist of details about the patient’s history of the complaints, any patient observations, treatment plan or medical management, and the treatment outcome. Providers that fail to document relevant data in the medical record can implicate a significant deviation from the standard of care.