Insurance Company Record Requests

The APA has provided guidance to members for responding to requests from insurance companies for patient records [see page 6 of the March 2015 MPS News].  These requests are for “Risk Adjustment Audits” conducted so the plan can participate in risk adjustment analysis under the Affordable Care Act.  After being alerted by members to these requests, the APA corresponded with CareFirst regarding their audit requests, raising concerns regarding HIPAA provisions for confidentiality and patient consent, as well as reimbursement for copying records and indemnification of the psychiatrist.  In response, CareFirst decided to stop the audits, as did Optum; however, at least CareFirst has resumed the practice.

MPS members who receive such requests should reference the Patient Records Request under PPACA resource before responding, and request APA assistance with any questions or concerns as outlined in the resource.  Participating physicians and patients may be contractually required to supply the information requested. However, physicians should check with the requesting company to confirm the company’s authority to get the records and get patient consent before providing the information.