It happens almost every day: Practices already stretched thin with their existing responsibilities are asked to send hundreds of medical records to auditors for “review.” The additional work and stress from the medical records request pushes practices to their limits and seems excessive to most practice managers.
What recourse do you have for these voluminous medical records request instances? Check out what Medicare says so you know when you can push back and when you shouldn’t.
Know Who’s Making the Request
Your first step to determining how many records a payer can request is to investigate who’s asking. Although this may seem simple, the reality is that insurers often ask third-party organizations to do their audits for them. For instance, in the case of Medicare, you might receive a medical records request directly from the payer, but in other instances the request might come from a recovery audit contractor (RAC), an organization that the MAC hires to perform claim reviews on their behalf.
The number of allowable review documents could differ depending on the requestor. For instance, CMS has advised the MACs to typically start with “limited reviews” of 20 to 40 claims on a prepayment basis. If issues are found among those claims, the MACs can then request more records.
The RACs, however, have more specific limitations, which are based on the practice’s size. These change from year to year, but currently they are as follows:
If your medical records request is coming from another type of auditor — such as a private payer or state Medicaid program — the number may differ from what’s above. The insurer should have their limit posted online, and if their request exceeds it, you should always ask for a reduction.
Ask for an Adjustment to the Medical Records Request
As with anything involving the health insurance program, you are within your rights to ask for a change to the medical records request if you feel it’s burdensome. To do this, you can either call, email or send snail mail to your insurance representative asking for a reduction in the number of records.
Make sure you file your request well before the response deadline. In other words, don’t wait until the records are due before you start negotiating to send fewer records. Instead, address it right away.
In cases where the requestor has limits in writing (such as the RAC limits shared above) and they’ve asked for more than that, you can simply say that their request exceeds the legal limit. If, however, you don’t have anything in writing regarding the insurer’s guidelines, you can still request a reduction.
For instance, you might say, “Our practice has received your medical records request dated Jan. 2, 2024. Our practice does not have the staff in place to submit 200 medical records before the Feb. 17 deadline, and we are officially requesting a reduction in the number of records we must submit, and/or an extension of time. Our current staffing would allow us to submit 60 records by Feb. 17.” The insurer may initially say no, and in this case, you may need to escalate the situation. You can ask for a supervisor at the insurance company or the RAC audit organization, and you may need to get your practice’s legal representative involved.
However, it’s worth it to request the requesting party to reconsider how many records they’ve requested to take the administrative burden off of your practice.
There’s so much more to know before responding to a request for medical records. Let healthcare attorney Michael R. Lowe, Esq., walk you through the process during his online training, Subpoena Release of Medical Records: Avoid Costly Response Errors. Sign up today!
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