10 Tips for Responding to a Records Request
By Barbara Griswold, LMFT (Updated September 22, 2017)
Many of us have practiced for decades without a health plan asking to look at a client’s chart. But lately, 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, 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 batch of record requests is from third party companies including Inovalon and Episource, and is related to risk adjustment audits under the Affordable Care Act (ACA). In risk adjustment, information from health care providers is used to determine the severity of illnesses and treatment costs for members in each plan. As a means of balancing risk between insurance companies who sell insurance on the ACA marketplace, health plans that have a greater number of lower risk (“healthier”) members are required to transfer funds to plans that have a greater number of higher risk (“sicker”) members.
Therefore, the records review should not be focusing on the medical necessity of treatment, or on recouping money from the therapist, it is more of a way to get a snapshot of the level of severity of the illnesses of the chosen clients.
So if you get a records request, what should you do? There is no correct answer here. But here are 10 tips when considering your response:
1) Check what your professional ethics codes and state law say about releasing records.
2) Notify your client. The letter may state that HIPAA doesn’t require client notification prior to release, yet many ethics codes and state laws require client permission to release records. While federal laws like HIPAA usually supercede state law, when state law is stricter, it will control.
3) Ask your client how they feel about the release. After all, it is their record. 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.
4) Make sure the plan’s release comply with state laws. For example, California Civil Code 56.104 (a) (1) through (4) requires the plan to state: the specific information requested, the specific intended use, the length of time the information will be kept before being disposed of, a statement that the information will not be used for any purpose other than its intended use and when the records will be returned or destroyed, and a statement that the entity will destroy or return the information before or immediately after the time has expired.
5) You might even ask for a new release. The Inovalon records request I received asked for SOAP notes and summaries related to surgical procedures, consultations, pathology, laboratory, and discharge — none of which I have. Clearly this request is primarily used for medical providers. While the Inovalon representative I spoke with said they wanted progress notes and all documents related to diagnosis and prognosis. However, since none of these was listed on the request, I could ask for a new written request specifically requesting these items.
6) If you keep separate psychotherapy notes, as defined by HIPAA, don’t release them. Unlike progress notes (which include session start and stop time, treatment type and frequency, diagnosis, treatment plan, symptoms, prognosis, and progress), psychotherapy notes are kept separately, and afforded greater privacy.
7) If you feel the release was adequate, and you release records, remember to only give the minimum information necessary to fulfill the request. Releasing more is a HIPAA Privacy violation.
8) If you do release records, and you are unable/unwilling to make the copies yourself you can contact the requesting party and they will typically 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.
9) No matter what you do, be sure to respond in some way to the request. Especially if you are a network provider, in your contract you may have agreed to cooperate with the insurance company concerning requests for information. It may be better to promptly respond to the carrier’s request, clarify the nature and the purpose of the information being requested, and to request the information that is legally and ethically required prior to the release.
10) 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 — And Probably Isnt; Writing Great Progress Notes and Treatment Plans” (pre-recorded, so you can view at your leisure); visit www.theinsurancemaze.com/notes for more information.