Take a strategic approach to Medicare Advantage records requests

Your practice might have received the dreaded envelope in the mail: a health plan is requesting patient records related to the Medicare Advantage Risk Adjustment Data Validation program. 

Although records request season can be a burden on optometric practices, it doesn’t have to cause undue stress, says Steve Eiss, O.D., chair of AOA’s Third Party Center Committee.  

“Sometimes when a practice gets this kind of request, the initial thought is panic. But this is nothing that they’re being scrutinized for,” he says. “[Insurance plans] are looking for diagnoses and data points to submit to Medicare for higher reimbursement.” 

So, take a deep breath and take action to reduce the workload: 

It’s time to start negotiating. 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. This gives your practice more time to take on the administrative burden of collecting the records. 

Ask to reduce the number of records you need to submit to comply with the request. Fewer records means less staff time devoted to compiling them. 

Ask for reimbursement. “Because the plans are doing this to elicit more reimbursement through Medicare and it takes staff time to compile this information, our time should be reimbursed,” Dr. Eiss says. An added bonus to asking for reimbursement: “When you start talking about compensation, it’s funny how the number of records they need usually starts reducing.” 

There are no set guidelines on what to charge, so request a reimbursement rate you think is reasonable, Dr. Eiss says, adding that he’s heard of payments up to $50 per record. Try to get an agreement that ensures you are reimbursed before submitting the records. 

“[Health plans] will almost always extend the deadline, reduce the number of records,” he says. “They’re definitely willing to work with you.” 

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. 

“We generally don’t recommend people just ignore it,” Dr. Eiss says. “Obviously this is part of health care, and we want to continue to have optometry be part of health care.”