Six HI Questions to Ask Your EHR Vendor for High-Volume Payer Requests

This article is published in collaboration with MRO.

Health information (HI) professionals nationwide anticipate a looming tsunami of payer requests for medical records. The Centers for Medicare and Medicaid Services (CMS) Medicare Advantage Risk Adjustment Data Validation (RADV) audit season peaks from March through April every year. During a RADV audit, CMS confirms that any diagnoses submitted by payers for risk adjustment are supported in the enrollee's medical record. And each new season brings an increasing number of payer requests.

This spike in payer requests leaves many HI departments overwhelmed and understaffed just as spring flowers start to bloom and vacations occur. Risk adjustment season 2024 is cause for heightened HI leadership concern as the US Department of Health and Human Services (HHS) vows to reduce fraud and abuse in the Medicare Advantage program.

Christi Grimm, the inspector general for HHS’ Office of Inspector General, presented the opening address at the RISE National Conference in March 2023. She reported a significant amount of fraud and abuse in the Medicare Advantage program.

Grimm noted that an estimated $113 million in overpayments was made to Medicare plans with 69 percent of these cases lacking documented support for risk adjustment. Primary culprits included diagnoses of depression, diabetes, and cancer. In-home risk assessments were another area of concern with 89 percent of the diagnoses resulting in risk-adjustment payments lacking documentation or any other records.

Grimm’s message to attendees was clear: “With growth in Medicare Advantage, comes more scrutiny of plans . . . I can tell you with great certainty that you will see us expanding our oversight of Medicare Advantage in the coming months and years.”

With this warning in mind, the upcoming RADV audit season will be even more daunting than in prior years with an unprecedented number of payer record requests. Unfortunately, the burden to fulfill these requests resides with an organization’s information technology (IT) systems and HI teams.

Plan Ahead to Be Prepared

Savvy HI professionals should plan now for 2024. Important questions must be asked of IT systems and HI departments to ensure data exchange with payers is secure, responses to requests are timely, and teams fully document each record submitted.

This includes staff evaluations and planning to ensure adequate coverage and accommodations for any vacation or leave of absence time.

HI Checklist for RADV Audit Season

Asking the right questions three months to six months ahead of the RADV audit season rush will prepare an HI department and IT team to manage heightened payer request volumes. The same questions are appropriate for release of information (ROI) or other interoperability vendors that may assist an organization with fulfilling payer requests.

Consider the following six questions well in advance of the upcoming RADV audit season to determine if your organization needs a better solution to manage audits across the board:

1. Is there an audit trail outlining what data was released to whom, when, and for what purpose?
2. What safeguards are in place to protect patient information? Are only specifically requested documents shared with the payer? In other words, does a vendor abide by minimum necessary standards or are they oversharing patient protected health information (PHI) with payers?
3. Does a vendor or current solution provide payer-specific key metrics via configurable dashboards regarding the volumes of charts being released, charts at risk, turnaround times, who receives charts, and for what specific reasons? 
4. Does a vendor have established access to a national network of payers and relationships with third-party retrieval vendors to expedite the process?
5. How effective is the HI team or ROI vendor in managing RADV audits? Were they able to execute on the requested volume effectively and successfully in the past?
6. Some exchange facilitators only require gentlemen's agreements with payers versus full-fledged partnerships. Check to make sure any solution to support payer audits acts in the best interests of an organization and its patients.

Finally, since HI personnel cost and administrative burden is significant during RADV audit season, staff must also be prepared well in advance. Staff are often overwhelmed with payer demands to fulfill requests while also maintaining privacy, compliance, and security. Volumes alone drive many HI leaders to hire additional staff or outsource request processing for an additional cost.

Manual processes are fraught with high cost and staff inefficiency. Now is the time to consider a new and more efficient approach to seasonal, high-volume payer request spikes. And where dollars aren’t available to hire staff and in cases where electronic health record (EHR) systems can’t perform every function required, new technology may provide the answer.

Angela Rose, MHA, RHIA, CHPS, serves as vice president of client success at MRO, where she is responsible for activities related to successfully onboarding new clients, account management, and corporate policy.

About MRO

MRO is accelerating the exchange of clinical data throughout the healthcare ecosystem on behalf of providers, payers, and users of clinical data. By utilizing industry-leading solutions and incorporating the latest technology, MRO is helping providers manage and release clinical data. For more information, visit www.mrocorp.com.