November 1st, 2015

Audits rule affects requested records

As the Affordable Care Act continues to unfold, a new regulation that requires that insurance companies conduct risk adjustment data validation audits on providers has caused some debate about how best to respond to requests for patient records.

The audits, also known as RADV audits, were designed to ensure that insurance companies remain competitive regarding the relative health of their served populations. Risk adjustment funds are distributed as a way to support companies that serve less healthy clientele.

The audit regulation should, in theory, apply only to insurance companies and providers working with plans sold through health insurance exchanges. Some providers, however, are seeing audits for private insurance as well, ostensibly to compare care provided through exchanges to that of commercial plans.

The result of the audits, while not directly affecting providers, will direct the flow of millions of dollars of federal funding for insurance plans. These “spot checks” will be done annually as a way to level the playing field.

The issue, according to Alan Nessman, J.D., senior special counsel, Legal and Regulatory Affairs for the American Psychological Association Practice Organization, is when records requested contain sensitive information.

For psychologists who record sensitive personal information along with clinical diagnoses, a request for a patient’s “full chart” can lead to privacy concerns, especially under the Health Insurance Portability and Accountability Act. The request violates, say some psychologists, the “minimum information necessary” rules of the privacy act.

“The main concern is with psychologists who keep all of their notes in one chart, comingling detailed information and impressions from therapy with the basic clinical information, such as diagnosis and treatment plans. We call this a combined record,” said Nessman.

“Since this information is not separated, psychologists cannot withhold from insurance companies information that would otherwise be protected from insurers in psychotherapy notes.”

The combined notes could also, in many cases, give insurance companies a burdensome amount of paperwork.

“These Risk Adjustment Audits focus on very narrow issues about the patient’s health status, so if a psychologist is producing 30-pages of detailed therapy notes, that is arguably providing more than the minimum necessary information that the auditor needs,” he said.

The APAPO has contacted several insurance companies to ask that they allow psychologists to extract clinical information from combined records. At this point, the organization was successful in working with Anthem and with Blue Cross and Blue Shield of Minnesota.

“We have asked our members to let us know if other companies will not accept this approach,” said Nessman. “We have not heard of any companies objecting to this.”

As the November deadline for audits approached, the APAPO experts were cautiously waiting to see how many psychologists would be affected. In the meantime, they recommend that psychologists think about altering their record-keeping in order to simplify the process if/when they do receive an audit request.

“Psychologists might consider options such as keeping a combined record but with very limited detail, keeping separate psychotherapy notes as a matter of practice, or keeping separate psychotherapy notes for only certain patients or certain sessions where there is a need for detailed records,” said Nessman.

By Catherine Robertson Souter

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