Note: This information is current as of Nov. 11, 2014 and does not constitute legal advice. Please also see the disclaimer at the end of this article.
As discussed in a previous PracticeUpdate article, some members have received letters from Inovalon requesting “full chart” patient records as part of an audit. Inovalon is conducting these audits on behalf of various health insurers — primarily Blue Cross Blue Shield (BCBS) companies such as Anthem/WellPoint Blue Cross companies in California, Ohio, Georgia, Connecticut and other states; BCBS of Minnesota (BCBSMN); and Independence BCBS. Emblem Health in New York is also involved.
The APA Practice Organization (APAPO) is working with state associations to assess these audits, starting with communications to Anthem and BCBSMN explaining our concerns. How you should respond depends on which insurance company is directing the audit, and how you keep your therapy records.
The audits are being driven by risk adjustment provisions of the Affordable Care Act (ACA), and are new to us and to health insurers. Passage of the ACA means a larger segment of the population has entered the market, many of whom were previously uninsurable.
Regulators have set up a Risk Adjustment Program to keep insurance plans with unhealthy patient populations competitive with those plans with healthier populations for whom care is less expensive. Funds from plans with healthier populations are transferred to plans with less healthy populations. The primary purpose of these audits is to annually and randomly “spot check” that patients’ health status and diagnoses are accurately reported, and to keep premiums low and competitive.
Our recommendations are based on two main concerns raised by these audit requests:
- Patient consent/notification requirements. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provisions allow for the release of patient information for audits. However, more stringent state confidentiality laws (not pre-empted by HIPAA) may require prior patient consent in most states affected by the audits; California requires a special notice to the psychologist and patient.
- The HIPAA minimum necessary rule. HIPAA stipulates that psychologists only release the “minimum necessary” information for the purpose of the request.
Members who keep separate psychotherapy notes as defined by HIPAA can just produce their separate clinical record. Members who keep a very lean single record with no sensitive details of therapy can also just produce that record.
Anthem and BCBSMN have confirmed with us that they are not requesting psychotherapy notes in this audit. We will verify with other auditing insurers that they likewise recognize that HIPAA protects psychotherapy notes from health insurers’ requests.
For members who keep a “combined record” that contains basic clinical information as well as extensive detail from therapy sessions, the issue of what to produce is more difficult. For a risk adjustment audit focused on verifying the patient’s diagnosis and condition, a combined chart with extensive notes and details from therapy is arguably much more than what the company needs (or wants).
Anthem has told us that it will let members extract just the information that is needed, as detailed below. BCBSMN has indicated that it will get back to us on this issue.
We expect that other insurers that sell insurance through the health insurance exchanges created by the ACA will begin conducting risk adjustment audits. The annual audits required by ACA may significantly increase the frequency of audits for members and the need to prepare for them.
We recommend that members who currently keep a combined record strongly consider:
- Keeping the details of therapy in separate psychotherapy notes.
- If the nature of your practice does not require you to record those details of therapy sessions, just omitting them from your record and keeping a lean record.
Because risk management audits focus on accuracy of diagnosis, members should also be mindful that the clinical record supports the diagnosis listed.
These recordkeeping approaches will simplify your task should you face further audit requests in the future. APAPO will provide more details on these recordkeeping considerations in future issues of PracticeUpdate.
We will continue to provide updates on these audits in future issues of the PracticeUpdate e-newsletter, in the Insurance Advocacy section of APAPO’s Practice Central website, and to state psychological association leaders as it becomes available.
Note: This article is provided for informational purposes and does not constitute legal advice. The information should not be used as a substitute for obtaining legal consultation prior to making decisions regarding individual circumstances.
Click the tabs below for information for members based on the insurance company directing the audit.