09/23/2015

Medicare Advantage Risk Adjustment Record Requests: Your Rights

NYSPMA and APMA have been receiving questions from members on Medicare Advantage (MA) risk adjustment records requests. Below is information on your rights and responsibilities as a provider.

 Providers’ rights and responsibilities for providing medical records or access to medical records, depends on the purpose of the audit. If the purpose is to ensure that the provider has billed appropriately, then he or she must generally provide the records without charge. If the purpose of the audit is for risk adjustment purposes, then provider rights and responsibilities depend on whether he or she is a contracted provider, deemed provider, or non-contracted provider.

MA regulations explicitly state "MA organizations must obtain the risk adjustment data required by CMS from the provider, supplier, physician, or other practitioner that furnished the services." 42 CFR 422.310(d)(3). Many MA plans have opted for chart reviews to ensure all the relevant diagnostic data have been captured. In order to submit a diagnosis to CMS, the diagnosis must be documented in a medical record. Note that MA plans frequently contract with third parties to obtain relevant risk adjustment data.

Contracted Providers should refer to their contracts in order to understand their rights with respect to record requests and audits.  Most provider contracts obligate the physician to provide medical records for review and audits, including for risk adjustment purposes. MA regulations permit MA organizations to include in their contracts with providers, suppliers, physicians, and other practitioners, provisions that require submission of complete and accurate risk adjustment data as required by CMS. These provisions may include financial penalties for failure to submit complete data." 42 CFR 422.310(d)(4). If there is no obligation to provide the records to the MA plan for purposes of collecting risk adjustment or quality data, then physicians may ask for payment for the time and work involved in responding to the request. 

Some contracts may give physicians rights such as limiting audits to reasonable business hours and/or providing for adequate notice to produce the records. They may address whether a physician is required to furnish on-premises access to the record reviewers or whether the plan will pay for the provider to copy the records and furnish them to the plan.  If the contract does not specifically address these issues, physicians should look to the plan’s provider manual or other repository of policies and procedures with which the contract requires them to comply.  Often these documents contain significant detail about record requests. 

If the MA plan requesting the chart review is a private fee-for-service plan and the provider does not have a written contract with the plan, he or she should refer to the plan’s terms and conditions.

Deemed Providersare providers who are deemed to accept a plan’s terms and conditions whenever they provide non-emergency services to an individual they know is a plan member. The terms and conditions are listed on the plan’s website. Frequently they will obligate physicians to furnish medical records without payment. They may include additional rights and obligations with regard to record requests, similar to contracts.  If the terms and conditions do not address whether the plan will pay for providing records, deemed providers may ask to be paid for the time and work involved in responding to the request. 

Non-Contracting Providers have no obligation to furnish records except to the extent they are needed to confirm that payment was appropriate. Non-contracting providers who receive record requests for purposes of collecting risk adjustment or quality date may ask for payment for the time and work involved in responding to the request.

Regardless of contracting status, if a request for medical records seems onerous, physicians should call the MA plan to see if it is possible to work out a more reasonable schedule or mechanism for providing records.  Physicians may want to ask for a longer time period, a reduction of the number of records requested at one time, or ask that the plan send in someone to copy the records in their office rather than requiring staff to make copies and send them to the plan. Given plans’ interest in obtaining the information, they will often agree to reasonable requests. 

Information on MA risk adjustment can be found in the APMA Private Insurance Resource Guide (PIRG), located at www.apma.org/PIRG, in Chapter 10: Understanding Medicare Advantage Plans, specifically on pages 7-9. In response to state component and member inquiries, the February 2015 issue of APMA News features a reimbursement column article on this topic as well. 

If you have additional questions, please contact the APMA Health Policy and Practice department at healthpolicy.hpp@apma.org.