What to do when an insurance carrier requests that you mail charts

What not to do

Don’t ignore the request – it will not go away

• While there is a cost to prepare your records, your participation agreement includes an obligation to cooperate with such audits, and generally copying and mailing the records is considered part of the definition of cooperating. You could ask the carrier to come to your office to the copy instead, but it’s not advisable, as they could refuse, and if they agreed on the disruption in your office of some outsider in your records may not be desirable.
• Failure to respond becomes grounds for termination from a health plan. Termination from a health plan becomes a reportable event to the office of Professional Medical Conduct.  Termination by the plan or by the physician does not end the right of the payer to review the charts.
• Terminating participation with a health plan during an audit may not be advisable. If the findings are negative and the plan wants to retain you for their marketing needs, you have some leverage in negotiating the outcome.  If you terminate participation, the plan has no reason to work with you and will most likely seek the maximum recovery.

Never just send the charts in response to the request

• Once you send the records, they already have your billings, they have the “evidence”, and there is no turning back the clock on what is in those records.
• Anything you send can and will be used against you in a court of law, in any action that follows.  Know what you’re sending before the charts leave your office.

Plan Disclosure Requirements

If you are participating with a carrier, your contract allows them access to your records.  If not participating, the carrier’s contract with the enrollee/patient gives them the right to access charts on patients for whom they have made payments or been asked to make payments.  The party that pays the bill has the right to view the medical records to verify that services provided are consistent with the billing.

The insured patient, as part of their enrollment, has given the health plan or insurance carrier authority for you to release the medical records to the carrier.  However:

• The insurance carrier is entitled to the records only for the time that they covered the insured, not necessarily the complete record.
• If the chart contains identification on the treatment or diagnosis of a protected class of records they may not be released to the health plan or carrier in the absence of specific patient authorizations that meet NYS regulations. The standard authorization is given to the carrier at the time of enrollment generally does not cover these conditions.
• Alcohol diagnosis or treatment in a facility licensed for that purpose
• Substance abuse or diagnosis or treatment at a facility license for that purpose
• AIDS/HIV positive diagnosis or treatment
• Certain mental health diagnoses and treatment

Do not to send records unless the requesting party is known to you, includes in their request a statement that they follow HIPAA standards, and include or represent having appropriate patient authorizations in their possession.

Read More: Hackers breach 75K sensitive personal data from HealthCare.gov

What to Do

1. Buy time – send the insurer a certified letter acknowledging receipt of their request. Their request generally requests records within 30 days.  Your letter should tell a “white lie”.  “We have received your request and wish to be fully cooperative with your request.  Unfortunately, your request arrived just as the physician was leaving for (*Europe, * the office is being renovated, * the physician is finishing a research project*) which will delay our ability to respond.  However, we expect to provide you with the records no later than (date some 60 days from their letter). Should this pose a problem for you, please advise us in writing immediately.”
2. This will give you time to review your situation, obtain an outside review, and consider your options.
3. Failure to respond is interpreted as a refusal to cooperate.
4. Review the charts before you send them to assure that you’re not giving them more than they’re entitled or “protected records”.
5. Call in an expert. As good as you think you are in reviewing your charts, an independent expert that will review your charts and let you know if you are on solid ground with your coding/documentation. Remember, just like a person trying to proofread their own writing, “proofing” your own records will only justify their correctness in your mind, not provide a confirming expert testimony.
6. Are you an expert? While you may be comfortable reviewing your own charts for compliance with documentation billing requirements; you may find that a third-party review is most beneficial. Remember that people reviewing your charts at the health plan or insurance carrier are on the payroll of that payer and very experienced at the requirements for medical record documentation.  They’re looking at the charts from their perspective.  Perhaps you should have someone looking at your charts with you in mind.
7. An outside expert is more objective
8. Properly qualified, the expert can help you argue points in your favor if the payer pursues an action

Where to find an expert

Certified Procedural Coder – Physician Specialty (CPC-P) is what you are looking for.  You can obtain recommendations from colleagues, your professional society, health care attorney, or from the American Academy of Professional Coders.

Read More: What to expect from the United Health’s EHR

Findings

1. If your expert confirms the correctness of your documentation in support of your coding, send the records, confident that if the payer comes back at you, you can have an expert argue with their expertise in your defense.
2. If your expert identifies deficiencies in your records, you may be able to use other supporting work, with their guidance, such as lab reports, consultation reports, to bolster the charts that you are sending.
3. If your records are not supportive of your coding, seek competent legal advice and develop a strategy for responding to the payer.
4. You can reduce your initial cost of review by having the coding expert review your records and provide their professional opinion of the coding that is supported by your documentation. Do not show them what you billed.  You then compare what you actually billed to what the professional would have recommended being billed.  If the same, you are on good ground, if not, get the attorney.
5. The reason is that if your coding expert sees what you billed and what the documentation supports, and identifies that there are discrepancies, that coder could be subpoenaed in an action against you and then your expert is now an expert for the opposition.
6. You can avoid this up front, for a few extra dollars by having an attorney technically “hire” your coding expert. If their engagement is by your attorney (any attorney will do at this point, real-estate, matrimonial, etc.) their work and their findings are protected under client-attorney privilege.

Get real about what your charts say and what you billed.