11 Tips for Responding to a Records Request: Risk Adjustment Audits
By Barbara Griswold, LMFT (Updated March 17, 2021)
Many of us have practiced for decades without having a health plan ask that we send a copy of a client’s chart. But in the last few years, providers are having the new experience of receiving records requests from third party companies hired by health plans, including Anthem Blue Cross, Blue Cross/Blue Shield, HealthNet, MHN, Medicare, and Aetna.
You may have read my articles about Equiclaim’s 90837 CPT code provider profiles which included a threat of records review (if you missed those articles, click here). However, the latest requests are from third party companies including Inovalon, Ciox Health, Coativity, Datafied, Episource, and Alliant. While these companies are hired by health plans to do a variety of projects, the latest project is carrying out “risk adjustment” audits under the Affordable Care Act (ACA).
In risk adjustment, information from health provider records is used by the plan to determine the severity of illnesses of plan members. After these assessments, health plans that have a greater number of “healthier” members are required to transfer funds to plans that have a greater number of “sicker” members. Think of these records requests as a way for the health plan to get a snapshot of the health of their plan members so they can forecast future expenses for their members as a whole, and to recoup money from other health plans who may have spent less.
The good news for providers and clients? In my mind, these are the least threatening of all the types of records requests. Not a wink of sleep should be lost when thinking about them. Risk adjustment requests are not for the purpose of determining the medical necessity of treatment. The plan is not looking at whether or not to approve future sessions. They are not reviewing your care. It is not a documentation review aimed at critiquing the state of your notes (so don’t panic if you have lousy notes). It will not negatively affect the member’s coverage, premium, or your provider agreement. Best of all, the goal is not recouping money from the therapist or client. So while annoying, they shouldn’t be a cause for concern.
Note: While these requests may be intimidating, you may find the requesting agencies are quite disorganized. They may call for information (to verify your fax or address) several times, even if you already responded. They may call to say they never received records even when you already sent them. So just expect this.
So if you get a records request, what should you do? There is no correct answer here. But here are some tips when considering your response:
1) Confirm it is a Risk Adjustment Audit. Carefully search the letter you received for the words “risk adjustment.” Otherwise, the rest of the advice I give here may not apply.
2) Don’t panic about the deadline on the letter. Call the requesting agency and/or the health plan and ask for an extension, if you’d like more time. They all seem very willing to give more time.
3) Ask them what they REALLY need. In most cases, you probably don’t need to send your notes at all! Inovalon, Anthem, and Ciox Health representatives have told therapists various things, from “all we need is dates of service, general reason for treatment, basic description of what you was worked on, and some of the treatment plan” to “all we need is a treatment summary with client name, date of birth, diagnosis, treatment plan goal, session modality/frequency (average), length of sessions, referrals, tests and/or medications, progress, and prognosis.” They usually state your treatment summary should be no more than one page. In fact, some therapists were told it was sent to them in error and to ignore the letter. Document your call, who you spoke to, and what they said.
4) Note carefully the time frame on the release. Any notes or information you release should be restricted to service provided during that time period.
5) Check what your professional ethics codes and state law say about releasing records.
6) While HIPAA doesn’t require client notification prior to release in this case, if you don’t want to release even a quick treatment summary, you could state you are uncomfortable releasing without client consent. However, requesting agencys and health plans seem to be pushing back more on this, and tell you the client has already signed a release for these type of administrative inquiries when joining the plan. I recently tried to refuse since I had no release, and I got an “urgent fax” from the health plan (Anthem Blue Cross of California) insisting that “as stipulated in your contract, you are required to respond to requests in support of risk adjustment…”
7) If you decide to talk to your client about it, explain the purpose of the records request to them in the most objective way possible. Document the conversation in their chart, and get a written release if they approve it. If your client doesn’t want you to release records, you could inform the plan that you are reluctant or unwilling to go against your client’s wishes (if this is your situation, schedule a consultation with me, and as part of the consultation I can provide a sample refusal letter). In fact, when a provider emailed Inovalon that her client was reluctant to give a release, Inovalon responded “please inform the patient that not participating with the request will not result in being dropped by Blue Cross Blue Shield Health plan.” (March 2021)
8) The correspondence you receive may seem confusing, since it says not to release your psychotherapy notes. But remember, there are two types of notes — progress notes, which include session start and stop time, treatment type and frequency, diagnosis, treatment plan, symptoms, prognosis, and progress, and psychotherapy notes as defined by HIPAA (sometimes called process notes), which are optional to keep and may include your analysis, thoughts and feelings about the case. Psychotherapy notes are to be kept separately from the rest of the client chart, and are afforded greater privacy, so don’t release these.
9) Give the minimum information necessary to fulfill the request. Releasing more is a HIPAA Privacy violation.
10) If you do release records, and you are unable/unwilling to make the copies yourself, you can contact the requesting party, and they may send someone out to make the copies. Also, while this is not advertised, you can get sometimes get reimbursement for your time spent complying with the request. The Inovalon representative I spoke with told me reimbursement is on a case by case basis — for more information, contact them.
11) No matter what you do, it’s probably a good idea to respond in some way to the request. They often keep calling if you don’t.
Do you cringe when you think of someone reading your notes? Vow to start keeping better records — now. Remember that well-written notes could serve as your best defense in a disciplinary or ethics complaint — or to help your client get much-needed treatment in treatment review. Check out my webinar “What Should be In Your Charts: Writing Great Progress Notes” (pre-recorded, so you can view at your leisure); visit www.theinsurancemaze.com/store for more information.