Risk Adjustment Chart Review

heartyoga

Guru
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122
Location
Cookeville
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We are a solo practitioner but sees patients with heart problems and other co morbidities.

Bec we are in a rural area and not a lot of specialists here, we see a lot of complex patients. We are getting swamped with request for records from insurances, like 120 from BCBS, 80 from Humana, 50 from Aetna, etc.

We are drowning and had to pull resources to be able to comply with this requests.

I understand that it is in the contract that we should pull the records as requested but i think it's unfair that the insurances are getting money from the government, and we are doing all the work.

Any thoughts?
 
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Obviously the higher the patients risk score is the sicker they are. The insurance companies are then in turn putting out more money for these patients. If the chronic diagnoses are NOT being captured but the patient is still requiring these "higher needs" visits because they are indeed sicker the insurance company is not getting reimbursed properly from CMS and are losing money. The insurance companies are not "making" money they just want to be paid properly for the services that they are already paying the providers for. The appropriate risk score for each patient will also then allow the insurance company to prepare for the following year to insure the providers will get paid properly for their increased services and the patients can get the care they need.
 

thomas7331

True Blue
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2,248
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We are a solo practitioner but sees patients with heart problems and other co morbidities.

Bec we are in a rural area and not a lot of specialists here, we see a lot of complex patients. We are getting swamped with request for records from insurances, like 120 from BCBS, 80 from Humana, 50 from Aetna, etc.

We are drowning and had to pull resources to be able to comply with this requests.

I understand that it is in the contract that we should pull the records as requested but i think it's unfair that the insurances are getting money from the government, and we are doing all the work.

Any thoughts?
This is a common problem and many practices will actually negotiate a clause into their contracts to limit the number of record requests that their payers can ask for each month. You may wish to review your contracts to see if there are any such limitations in them, and if not, work with your network representatives to try to get some relief from this. Another alternative is that you may be able to ask the payer auditors to do this work on site and send someone out to your office to review the records in-house to avoid having to copy and send the records to the reviewers. Or, if you have an electronic health record, you may even be able to arrange for the reviewers to access your system remotely and do the reviews.

In my experience, the payers are often willing to work with you on this if they want you to stay with their network, but you'll need to voice the concerns to them and make them aware of the burden they are creating for you.
 

kksmom

Contributor
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15
Location
Wausau WI
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Medical Record Requests

It may also be a consideration to allow the insurance company electronic access to their member records in your EHR.
 

mcwriter

Contributor
Messages
10
Location
Braintree, MA
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Payer burden

I would strongly encourage providing space for reviewers to work onsite (give them a desk and a decent lamp) or even better provide electronic access with a secure server to eliminate the burden of pulling and copying records. Good luck.

Mary Fitzgerald, MS, RN, CPC
 
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