Reminders from the Risk Adjustment Team

The Risk Adjustment Team will begin a major undertaking of a record review/audit for all our Medicare members. We will be requesting records on all our Medicare members over the next several months. This is a necessary task to remain compliant with CMS.

We ask that you complete the request within the timeframe as requested and contact the email listed on the fax sheet should there be any issues with the request. We will only request the minimum necessary for our review and look forward to working with all the offices.

Look for our requests to start very soon! Thank you in advance for all you do for our members, and we appreciate your cooperation with this review/audit. We also appreciate your time.
Reminder: Medical Record Requests

You will be asked to respond to a medical record request by HealthTeam Advantage, a Medicare Advantage (MA) organization. This request is based on diagnosis data submitted to the Centers for Medicare & Medicaid Services (CMS) as a result of services you provided to Medicare beneficiaries during the calendar year (CY) 2020. The purpose of this request is to validate diagnoses that were sent to CMS for determining health status adjusted payments under risk adjustment. Risk adjustment modifies capitated payments made to the MA organizations based on the health status of each enrolled Medicare beneficiary.

It is important to note that physicians who submit requested medical records to MA organizations are not in violation of the Health Insurance Portability and Accountability (HIPAA) privacy regulations. In other words, patient-authorized information releases are not required for you to comply with this request for medical records. See “Health Insurance Portability and Accountability Act (HIPAA) Fact Sheet” below.

Please note that Federal regulations require MA organizations and their providers and practitioners to submit medical records for the validation of risk adjustment data (42 CFR §422.310). We will be asking you to release the individual’s medical records relating to care provided from January 1 through December 31, 2020. A list of required documentation will be attached at the time of the request.

As this is a time-sensitive review, we will be asking for a turnaround time of 7-10 business days for the return of the records. If the required documentation cannot be located, please reply to the fax provided letting us know, by the member’s name, that you “Cannot Locate Chart (CLC).” Please also explain why the chart is not available.

Examples:

• Not seen during the year requested
• Member transferred to another provider (please provide a name when possible)
• Member deceased

Health Insurance Portability and Accountability Act (HIPAA) Fact Sheet

The collection of risk adjustment data and requests for medical records to validate payment made to Medicare Advantage organizations does not violate the privacy provisions of HIPAA. Therefore, a patient-authorized release of information is not required to submit risk adjustment data or respond to a medical record request from Medicare Advantage Organizations (MAOs) for data validation.

Specific sections of the HIPAA privacy regulation are referenced below:

General Reference:

45 Code of Federal Regulations (CFR) Part 164, Standards for Privacy of Individually Identifiable Health Information, Final Rule

Web Link: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html

CFR References:

45 CFR Part 164, Subpart E, Section 164.501—Definitions
45 CFR Part 164, Subpart E, Section 164.502—Uses and disclosures of protected health information: general rules
45 CFR Part 164, Subpart E, Section 164.506—Uses and disclosures to carry out treatment, payment, or healthcare operations