How to Manage Rising Medical Record Release Requests from Payers

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Payer medical records review conducted every year include the three major types, HEDIS (Healthcare Effectiveness Data and Information Set), Medicare/Medicaid Risk Adjustment, and Commercial Risk Adjustment. A HEDIS review is done by a health plan/insurer to measure the quality and effectiveness of patient care delivered to plan members. Healthcare organizations experience a steady rise in HEDIS/Risk Adjustment reviews as well as DRG/post-payment audits. Now, with electronic health information exchange becoming more popular, insurers are requesting direct access to provider EHR systems for automated medical record retrieval and review. This increasing trend of medical record requests from payers can be quite burdensome for healthcare providers.

Among the concerns providers have in allowing direct EHR access to insurance companies are -- the possible increase in post-payment reviews, denials and recoupments; patient disapproval; providers’ exposure to cyberattacks and healthcare breaches; legal and information governance concerns. In this connection, providers can consider the following tips.

• It is best not to allow payers unrestricted or automated access to the entire patient medical chart. Provide only controlled access to the information that the payer needs. If the payer needs data pertaining to medical necessity, load only that information. In this way, you can avoid sharing sensitive data unnecessarily and protect the patient’s privacy.
• When it comes to claims processing, payers can be provided manual access to claims-specific encounters, with all due security restrictions.

To efficiently manage payer record review requests, providers can consider certain strategies as those listed below.

• Start working as early as possible: The NCQA (National Committee for Quality Assurance) proactively announces the quality measures that will be targeted for review in the year ahead. This information is made available to both payers and providers. So, providers on their part can contact payers and health plans in December or January to discuss the ensuing HEDIS Review season. Thousands of medical records could be requested between January and May, and two important things to keep in mind are expected volumes of request and provider reimbursement.
• Establish robust relationships with payers and health plans: Whether post-payment audits or payer reviews, there may be different types of requests and deadlines. Provider ROI or Release of Information teams may not be very knowledgeable regarding guidelines for processing payer requests for medical records, or the time frame they have for responding. Payers could impose a shorter time frame when actually there may be a broader time frame. Similarly, HEDIS and risk adjustment reviews are seasonal and allow more than 30 to 45 days to produce the records. Providers must strive to establish stronger relationships with payers so that they can negotiate things to better effect. This will help to better manage the rise in medical record release requests. Consider establishing project due dates instead of 30-day completion.
• Use updated language in the managed care contract: The medical records section in a managed care agreement governs the payer – provider relationship and also specifies the payer cost to audit a healthcare provider. There could be language that obliges healthcare organizations to charge lesser than the actual amount required for the medical records release. Sometimes, the contract language may state “No charge” for all types of medical records. When there is large-volume medical record requests, HIM departments are overloaded and the cost to produce the records falls on the providers. So, there should be restrictions to hold payers responsible. When the contract language is refined, payers will become more selective, thereby reducing the workload and costs for the provider.
• Balance the cost burden: Payers can be requested to compensate for the medical records provided in a timely manner. Payers may be willing to reimburse for the manpower, time, and mailing costs related to producing the medical records. 
• Centralize all audit management functions: This will help enhance collaboration among the team members, and also save valuable time and resources.
• Ensure better communication with payers: This is essential to have a clear understanding of the requests made, to process records and to meet deadlines.
• Ensure comprehensive analysis of data in all records released to payers and plans. 

Providers need to safeguard patient privacy while allowing direct payer access to healthcare data. It is important for payers and providers to collaborate and work for the common good. This will help better manage payer demands, ensure realistic expectations on the part of payers, and reduce workload and costs for providers.

Disclaimer: The content in this article is sourced from various internet resources and is intended for informative purposes only. It does not constitute professional legal opinion. For a professional opinion, contact an attorney.