Medicare Advantage Risk Adjustment audits are overwhelming optometry practices

Doctors of optometry are receiving an unprecedented number of records requests related to Medicare Advantage Risk Adjustment audits. In some cases, Medicare Advantage Organizations (MAOs) are requesting several hundreds of records at once. 

Medicare Advantage Risk Adjustment audits are the primary way the Centers for Medicare & Medicaid Services address improper overpayments to MAOs. During an audit, Medicare confirms that any diagnoses submitted for risk adjustment are supported by the patient’s medical record. 

They aren’t meant to scrutinize optometric practices, but unfortunately doctors of optometry are getting caught in the crosshairs. “It is just a frustrating experience to place this quantity of burden on practicing ODs,” says Jeni Kohn, O.D., whose practice received requests for more than 1,000 records. 

Three AOA member doctors share their experiences. 

What happened when you first received a risk adjustment records request? What was your initial reaction? 

Jeni Kohn, O.D., chair of AOA-PAC: “I was confused. I had never received a request like this before and was concerned. Anthem was the first to reach out and asked for 599 records. Shortly after, we received one from Humana for 479 records. Since the initial contact we have received several smaller requests.” 

David Cockrell, O.D., chair of the Health Care Alliance for Patient Safety: “Our initial reaction was surprise at a request for almost 500 patient records dating back almost 18 months.” 

What steps did you take after receiving the request? 

Dr. Kohn: “The first thing I did was reach out to the AOA for clarification. They and Steve Eiss were very helpful in explaining the current climate and why we were getting such a large amount of records requests. After that, I reached out to the point person for each company to negotiate the number of records, payment and also clarify exactly what information they wanted.” 

Steve Eiss, O.D., chair of the AOA’s Third Party Center Committee: “We immediately contacted the company requesting the records (usually not the insurance plan involved). We requested a fee per record to be reimbursed to cover our time and supplies to provide this information.” 

Were you able to negotiate for any of the following: deadline extension, reduced number of records, or payment? What can you share about the negotiation process? 

Dr. Eiss: “Fortunately for us, the most recent requests have been manageable number wise, but we have been able to reduce numbers in the past. We were informed by the requestor that we were approved for $50 per record for reimbursement, and we did receive reimbursement a couple weeks later.” 

Dr. Kohn: “We negotiated for payment per record as well as a deadline extension. We asked several times for a reduction of the number of charts, but they seemed unwilling to negotiate on that particular issue.” 

How much staff time does it take to compile the requested records? Can you quantify the cost for your practice in terms of staff hours? 

Dr. Cockrell: “The process is ongoing, but it will take two to five minutes to retrieve, review and submit each record. [This will amount to an estimated] 20 and 40 hours and $500 to $1,000 of staff time.” 

Dr. Eiss: “It takes about 15 minutes per patient record to identify, compile and confirm with the doctor that the appropriate record is being forwarded, printed and sorted. That time can vary depending on the patient and the complexity of the records. If testing results need to be included, that increases the time significantly.” 

How many of these requests have you received over your career? 

Dr. Eiss: “We usually get at least a few requests every year. It seems that the number of records requested has really increased the past few years.” 

Dr. Cockrell: “This is the first time we have received a request for more than a few dozen records in one request.” 

Dr. Kohn: “This is the first risk assessment I remember receiving. The total of the risk assessment record requests we have received in the past few weeks is over 1,000.” 

What are your best practices and lessons learned? 

Dr. Kohn: “Reach out to the AOA for support or clarification. They are an incredible resource and are familiar with this topic and have feedback from doctors all across the country.” 

Dr. Cockrell: “If we continue to see Medicare Advantage patients, these types of requests, if ongoing, will continue to be a burden in staff time that could be better used for patient care and a significant cost to our offices.” 

What advice would you give other doctors about responding to these requests? 

Dr. Kohn: “Make sure you get paid upfront and ask for an extended deadline. They are pretty eager for the data, so you do have negotiating power.” 

Dr. Eiss: “These companies need this data from you to comply with Medicare and increase their reimbursements, so you hold all the cards. Any deadlines they reference are deadlines created by them. The records requested are determined by them. This is not a direct request from Medicare to you. Don’t panic, reach out to the company and determine your reimbursement, and forward the records once paid. I wouldn’t ignore the request but take your time and make sure you are appropriately reimbursed.” 

How to respond to Medicare Advantage records requests 

The AOA encourages doctors of optometry to take a strategic approach to these requests. 

• Call the phone number listed on the request (it might be for a third-party company that is contracted by the health plan) and ask for a deadline extension. 
• Ask to reduce the number of records you need to submit to comply with the request. 
• Ask for reimbursement. 

For more information on responding to risk adjustment audits, doctors of optometry can access the AOA resource “Risk Adjustment Audits/Records Requests-How To Respond.” For questions about how to get reimbursed for time and effort spent in responding to records requests, contact stopplanabuses@aoa.org.