Wiki Chart request, can a provider say no and refuse.

[tbragg36]

My provider is only contracted with Medicare. He says since he isn't contracted, he can say no and refuse to give the charts to the insurance carrier for review. Does anybody know if that's correct?

 

[thomas7331]

That's probably a question for an attorney to answer. If there is no contract in place, then there's no contractual obligation to turn over records, but there may be laws or regulations that govern this as well. Someone familiar with your state's laws and business practice regulations would need to be the one to answer this for sure.

But I would strongly advise the provider not to do this as it's likely to create more problems than it will solve. If he refuses to share medical records with the payer, even if he can legally do so, then that payer will almost certainly discontinue making payments to him at some point. Furthermore, if a provider is unwilling to allow a payer to view the records for services that they've paid for, that could create the impression that the provider may have something to hide and could make him the target of a fraud investigation.

 

[tbragg36]

Thank you for your input. About the only thing I could find was a contractual agreement will have a clause about participating in medical reviews. I would think since we are par with Medicare, we would have to if the plan is a MA. I found it interesting.

 

[Cynthia Hughes]

It is important to consult a health care attorney prior to refusing. HIPAA cannot be used as a reason for not providing the records. Under HIPAA, physicians can release PHI to payers for health care operations which include care coordination (eg, offering case management or other supportive services), risk adjustment, quality reporting (eg, HEDIS), fraud and abuse detection, in addition to payment. Filing a claim and receiving payment may give the plan certain rights to medical records. I think that the instructions on the back of the 1500 claim form (and thus the electronic equivalent) indicate that you must comply with requests related to government programs (Medicare, Medicaid, Tricare, etc.).