Health Plans Need Your Records: Know What’s Driving Requests and How to Be Prepared

Posted on July 26, 2016 I Written By

The following is a guest blog post by Craig Mercure, Chief Operating Officer of Payer Solutions at CIOX Health.
Craig Mercure
Audits. Reviews. HEDIS. Stars Ratings. No matter what, health plan record requests are growing by leaps and bounds each year. And the stakes are high for health plans to ensure they receive medical records in a timely way. What we also know – the large volume of requests and submission deadlines can put a drain on provider resources.

High volumes of medical record requests make it more important than ever for providers and health plans to work cooperatively and collaboratively. Here’s some helpful background on what’s driving the request for medical records and how providers can be prepared.

There are three primary health plan reviews that receive the most focus: Medicare Risk Adjustment, HEDIS Reviews, and Affordable Care Act (ACA) Medical Records Retrieval (MRR). While there are also other ad hoc requests related to fraud, waste and abuse (e.g., Risk Adjustment Data Validation (RADV), Medicaid, etc.), these three health plan reviews cause the most provider abrasion. Medical practices are getting hammered by them.

Say, for example, that a provider chooses 10 health plans. That provider is going to receive requests from each plan for all three of the main reviews, as well as the ad hoc requests. This has a major influence on record release and all other staff members that are impacted by it. The operational impact of receiving, verifying and fulfilling these requests is growing every year.

Here’s how the top three health plan reviews break down:

Medicare Risk Adjustment (MRA) reviews documentation and diagnosis codes to ensure proper reimbursement from the Centers for Medicare and Medicaid Services (CMS). Most records are retrieved from the primary care physician (PCP), specialty doctors, and in-patient stays—wherever the true value of a particular chart may reside. The MRA reviews typically begin in June and goes through early January.

Volumes have skyrocketed to 18 million record requests over the past several years. Plans are prioritizing Medicare Advantage plans and want to research every member. Therefore, depending on the percentage of Medicare Advantage patients seen by an organization, this review can hit providers hard. Medicare Risk Adjustment reviews are most prevalent in late summer and early fall with the end date for all plans to submit all 2015 diagnoses by January 31, 2017.

Two of the primary pain points for health plans are revenue and quality of care. Consider this hypothetical scenario. A healthy Medicare Advantage member has a score of zero. However, if that member develops diabetes within a given year, the score grows to 2.8. The health plan would receive 2.8 times the normal Medicare expenditure to care for that patient. While demographics and regional data also contribute to determining true ratings, this example is very realistic.

From a quality perspective, the health plan’s purpose for medical record reviews is to identify patients with chronic disease before they fall through the cracks. Plans attempt to effectively communicate with members and secure PCP visits before more costly encounters such as emergency or acute inpatient care occur.

Healthcare Effectiveness Data and Information Set (HEDIS) Reviews are driven by the National Committee for Quality Assurance (NCQA), a 501(c)(3) not-for-profit organization dedicated to improving the quality of health care so patients can make informed decisions about which plan they want to choose. HEDIS collects measures from plans, PPOs, physicians, and other organizations which is fed into a 5-star rating system. This rating system has become a marketing tool to help patients find the best health plans. It’s intended to allow patients to make “apples to apples” comparisons of health plans, similar to how you might shop for a car. The review season is typically February to mid-May.

Affordable Care Act (ACA) Medical Records Retrieval (MRR) is in its first year. These reviews are conducted during the same time frame as HEDIS. ACA-MRR has adopted similar risk methodologies as Medicare Advantage.

For providers, dealing with these reviews has become part of doing business with health plans. However, the amount of operational planning and time required to keep up with all the various requests can be monumental. Each provider site is configured differently in terms of medical record systems and IT security. Many providers outsource the chart retrieval (also called release of information—ROI) function to relieve the burden.

Gathering data in the trenches

Information to fulfill the health plan request may come from PCPs, acute-care hospitals, extended and rehabilitation facilities—wherever the health plan determines that the chart holds the most value. Also, caregivers provide medical records to health plans in a variety of ways. These include, but are not limited to: remote access, portals, secure FTP, CDs, mail, flash drives, emails, scans, and the old-fashioned standard—printed paper. While paper is dwindling, some still exists.

The majority of Medicare Advantage and ACA reviews are at the provider level. Sometimes thousands of records are involved. This can be a huge burden on physicians. Most health plan reviewers are interested in documents describing face-to-face interactions between clinician and member, such as progress notes and encounter notes based on specific dates of service.

For health plans and chart retrieval companies, the goal is always to obtain the necessary information with a minimal amount of provider abrasion. Two specific technology capabilities help smooth the process.

Electronic documentation embedded within the provider’s EMR

Various EMR systems and provider sites capture patient encounter notes differently. Some locations might not capture or maintain the encounter and progress information that is needed in an easy-to-retrieve electronic format.

Remote connectivity to retrieve information

Remote connectivity allows real-time access for the data needed by the health plan or chart retrieval service, mitigating the need for labor-intensive processes and onsite technicians.

An experienced chart retrieval service, like CIOX Health, satisfies the information demands of health plans while also reducing operational workload for providers. They’re responsible for securely linking both sides of the health plan review equation.

Experience eases chart retrieval

A chart retrieval service that repeatedly contracts with a specific health plan for reviews gains a year-over-year advantage. They’ve already connected to all the various provider systems and obtained security clearance. Every year they spend in the trenches, they learn and gain experiential data—giving them a head start for next year’s audit season.

Providers want to be fully compliant with health plan requests. They want to honor the request as quickly and efficiently as possible. Provider preference is to work with one chart retrieval service versus multiple ones over several health plans.

A single service can also field calls and inquiries from all the various health plans. Health plans want records to meet their review requirements, and they can be aggressive if records are past due. An experienced chart retrieval service helps both stakeholders move efficiently through the process—including remote connectivity—to meet health plan deadlines.

Finally, a centralized health information management (HIM) department is another way to ease the burden for providers. With centralization, all records and requests are aggregated. While centralized HIM is common practice in hospitals and health systems, it is not always feasible for physician practices and medical groups.

Cooperative steps must be taken to support health plan reviews while also reducing provider abrasion and operational costs. By working together, both plans and providers remain satisfied and smooth the process for everyone involved.

About Craig Mercure
Craig oversees all aspects of business development, including strategic planning, sales, client services, marketing, product development, finance and communications. He also leads the infrastructure development of the company as it grows, which includes: systems, processes, pipeline management, trade support, marketing, facilities, personnel recruitment and development. Over the past 15 years, Craig has worked in executive leadership positions within the electronic medical record and medical documentation industry.