They Want 100 Charts to Audit – REALLY?
Audits are on the rise in a major way. Some payers, particularly Medicare Advantage Plans under Humana and BCBS, are targeting vision care submissions made through the vision plan they are subcontracting with for routine care. In many cases, this is EyeMed. You may see a statement that they are addressing risk assessment and HEDIS issues. True on both counts, although most commonly these are HEDIS audits with an emphasis on care for patients who are diabetic or pre-diabetic, as indicated by their medical record with the Advantage Plan payer. They are attempting to verify the patient had a comprehensive eye examination, usually including a dilated ophthalmoscopic evaluation – a stated requirement for diabetics in the EyeMed provider manual. Most have a statement that the audit can be used for other assessments, essentially a standard medical records audit for coding compliance and proper medical records documentation to support the claim. This statement is very true.
Social media is full of misinformation and often comical comments regarding compliance with audit requests. Common questions surrounding these audits are as follows.
Do I have to send them the requested records?
Payer provider contracts will always contain a clause establishing their right to conduct audits, essentially for whatever reason they want. Without violating the terms of the provider agreement, doctors do not have the right to refuse to participate in the audit process.
I am not a provider for the Advantage plan requesting the records – I only provide services under their vision plan. Do I still have to release the records?
The Advantage Plan has essentially contracted out routine vision care services to a vision benefit manager. They maintain every right to review the care provided under the contracted vision plan.
The request is not from the medical plan or the vision plan – it is some entity I have never heard of, stating they represent the payer. Do I still have to send the records?
Payers rarely audit their own medical records anymore. They will contract with an independent third-party audit company to perform these services. The company they contract with essentially has the same rights and falls under the same stipulations as if the request came
directly from the payer.
They just say they are acting on the request of the payer – how do i know they are legit?
If you have any doubts about the requested audit service, you can always contact the payer for verification.
Does my patient have to authorize the release of their medical records to the payer under HIPAA regulations?
HIPAA specifically excludes any requirement for patient authorization related to medical record audits. Requiring patient release by HHS is considered to be a violation of the medical records release rules under HIPAA.
Can I charge the payer for the medical records?
While the answer is usually no, the answer should again be found in the terms of the provider agreement. If allowed, the amount you may charge is regulated by individual state law.
They are asking for a very large number of records? Can i negotiate a decrease in the number of records requested or ask for an extension in time to supply the records?
You are free to discuss these requests with the requesting audit service. Paying attention to the time requirements is extremely important. Many doctors create a bigger problem and increase exposure for themselves because they do not reply in the required timeframe. Make sure you are aware of time limitations, which will be stated in the audit request. Time extensions are commonly granted, but the number of records is typically set. Some doctors have reported that they negotiated a decrease in the number of records. You can always ask – all they can say is no.
After the audit, I received a request from the same payer for even more records. Why?
A secondary request almost always signals a focused audit – the payer has identified some concern from the predominantly HEDIS audit and is following up for more information. While not always an indication of something wrong, you might consider having a trained auditor review the records and provide advice.
I received a very negative response to the audit with a request for fine payment and threats of removal from the provider panel. What now?
Do not go further into these dark waters alone. Reach out for assistance from trained auditors in a reputable compliance company. They understand optometric care, medical records, know what to look for and what questions to ask. Do not rely on advice simply because someone states they are a certified coder or someone not in the eyecare field.
If you have questions or need help with an audit, contact us at info@PracticePerformancePartners.com