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Thread: Risk Adjustment Medical Records Requests

  1. #1

    Default Risk Adjustment Medical Records Requests

    AAPC: Back to School
    My small practice has found itself absolutely swamped with medical records requests from Medicare HMO's for the the purpose of Risk Adjustment Auditing. We sent out 700 sets of medical records just this month at a significant cost to our practice, and it was a daunting and time consuming task to say the least.

    It is my understanding that we can make no charge for these records as they are for government use. My doctors want to see this in writing in a CMS document. I have spent hours searching and cannot find a document that states what our responsibilites and rights are as providers. Basically, I need to know if we can charge the HMO for these records, and I also need to know if there are any limits on how many sets of records one HMO can demand at one time.

    I'd be so very, very grateful if someone here could point me to a CMS document that contains this information.

  2. #2


    i believe if you are sending the record to the MAPD or medical group, that depends on the terms on the provider contract. Some contracts may state whether physicians can charge a fee on medical record copies or not.

  3. #3
    Join Date
    Apr 2007
    Martinez, CA


    I do believe it depends on the terms of your contract. It's safe to say that you would be required to provide records at the request of the insurance company, but you may be able to charge them for records.

    As a care provider to MA patients, your practice is responsible for having documentation that properly supports the diagnoses that were submitted.

    Being on the other side of the table, it's very nice when providers don't give us a hard time about getting us records. It just makes everyone's life more difficult. I know it seems like extra, unnecessary work, but it is very important.

    Looking to the future, most of the extra work and cost involved in pulling these records could be eliminated with the implementation of an EHR.
    Brian Proosow, CCS, CPC
    The Permanente Medical Group

  4. #4
    Join Date
    Apr 2007
    Coastal Coders


    You are also allowed to say to them not now. We just do not have the time but you are welcome to come by and collect them yourselves. Just a thought to slow them down.
    700 record requests seem like an inordinate amount.

  5. #5


    Thanks for all the input. Along the lines of venting (sorry), our office does not mind in the least to comply with REASONABLE requests. The demands from MA's, however, are so out of control that our bottom line has been driven to below the "break even" point. Providers have to look at that and act accordingly. It's a difficult situation to say the least. It looks as though we will be opting out of at least one MA contract due to imposed "over the top" administrative burdens. 500 of the 700 requests were made by one company, and they are refusing to reimburse us in any way for the costs. They did offer to send a representative from their company to collect the records - at an astronimcal cost to us! We have a contract with them that states they will reimburse for medical records, however, they state they do not have to comply because the requested records are for "government use", yet I cannot locate any legislation that states we must provide records free of charge. We are looking at pursuing this via small claims court, and will be opting out of this plan unless a reasonable agreement is reached. As much as we believe in providing quality care to the Medicare population, we cannot go "belly up" in doing so.

  6. #6
    Join Date
    Apr 2007
    El Paso


    If you have a contract with them that states they will cover reasonable costs for you to provide the records (or something similar or specific), they MUST abide by their contract. It has absolutely nothing to do with "government records". You don't have any government records... you have PATIENT records (who are "members" of that particular health plan). Unless they have amended the the contract in writing or if there is language elsewhere in the contract that makes records for a "government entity" AUDIT an exception to this language, they are obligated to uphold their end of the contract. A good healthcare attorney can help!

    In an attempt to prevent fraud and to comply with healthcare reform legislation, these audits are the future of healthcare and are destined to become more frequent and in higher volume. My employer was recently asked to provide 600 records from the same carrier. They called on Thursday and wanted records on Monday!! They were told it would take at least 2 weeks and they would have to wait until we had the time and manpower to pull them (they waited). This was in addition to two other carrier's requests for several hundred records during the same period.

    I will be reviewing all our MA contracts for just this reason!

    Good Luck!
    Susan M. Garrett, CPC, COC
    Past President El Paso Texas Chapter AAPC
    Past Member AAPCCA Board of Directors
    cell 915-204-8333

  7. #7
    Join Date
    Apr 2007
    Baton Rouge


    How fitting that I just came across this thread...I received a request from a MA several weeks ago for a review of over 1,000 charts. I couldn't believe it. However, the person conducting the review is being very reasonable with scheduling the review on our terms; we will NOT be making umpteen million copies ; she will be coming onsite to review the charts. Yes, having an EHR would make this MUCH easier...can't wait until we have ours in place.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  8. #8


    We're in the same boat. We currently have 15 different MA carrier audit requests ongoing. I agree this has become extremely time consuming. They want to to work on improving RAF scores, but we're using all our time researching records. We don't send paper, we scan and send the records via secure email. We like to keep copies of everything we have sent and don't want to have to store all the copies. This also allows us to quickly retrieve the records when they say they haven't received them.
    Sherry Miller, MBA/HCM, CPC, CEMC
    Epic Management, LP

  9. #9
    Join Date
    Apr 2007
    Tacoma, WA


    Wow! That does seem like an "over-the-top" request for records!! I just started a new job as a Medicare Risk Adjustment Auditor for a small organization. So far the records requests I have sent have not been for more than 10 records at a time! Yes, our job is to make sure the diagnosis coding for chronic conditions is accurate and complete, that is how we get paid by CMS so we can pay the claims for the providers...but making it harder for providers to run their office is not acceptable. Sounds like time for a discussion and a review of the actual contract language. There should be an acceptable compromise so that the health plan gets the info it needs without causing undue burden on the provider office!

  10. #10


    I agree, ajs. We did meet with the health plan that was requesting the most records, 700+. We basically told them, they would get them when they get them. We can't stop running our business because of their unreasonable request.
    Sherry Miller, MBA/HCM, CPC, CEMC
    Epic Management, LP

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