Risk Adjustment

Best Practices to Cure a Common Chart-Retrieval Ailment: Provider Noncompliance

In recent years, with the idea of ‘preventive medicine’ gaining hold, focus has increasingly shifted to offensive efforts to keep diseases at bay. That doesn’t mean treatment isn’t necessary when disease begins; rather, prevention and early monitoring can help minimize, or even outright avoid, some illnesses.

The same applies to handling provider noncompliance — which can negatively affect record retrieval projects and a payer’s risk adjustment objectives.

Through targeted best practices, health plans can mitigate the effects of deficient provider response. One of the most effective prevention strategies is data management. This is especially important to solve issues that may imperil retrieval at offices identified (through data analysis) as housing a significant number of records. For these sites, provider noncompliance (or any issue, such as change of address) must be solved ASAP.

With the following best practices, payers can help ensure that non-participation doesn’t waylay the success of their record retrieval projects.

Prevention: Identify Risks Early

A partnership mentality between a payer and its record retrieval vendor can go a long way to successfully minimizing, avoiding or overcoming noncompliant providers. This should be established from a project’s start. As mentioned, active data quality management is vital to this partnership. As data accuracy directly affects a vendor’s ability to locate, retrieve and code charts, data risks must be identified–and strategy devised–as early as possible in a record retrieval project.

Proactive Monitoring: Identify Unforeseen Risks Early

Just as regular health monitoring can help identify health issues early, thereby allowing an individual to nip them in the bud, such vigilance can mitigate provider noncompliance. Payers should look for retrieval vendors who actively attend to provider noncompliance through methods such as:

  • Quality Assurance (QA)
    A vendor’s Outreach Consultants (OCs) must be well-equipped to minimize noncompliance with solid provider-outreach scripts. Also, it’s key that the OCs are following the scripts. To this end, QA monitoring of outreach calls can identify potential issues that may be contributing to noncompliance early in a project.
  • Proactive Staff Efforts
    As some PNP is unavoidable, record retrieval vendors should have specialists who proactively:
    • resolve issues with providers who don’t participate ASAP through internal project monitoring (thereby limiting client involvement)
    • monitor client-resolution feedback
    • identify and report high-priority non-participating providers

Timely Resolution: Solve Provider Noncompliance Collaboratively

Akin to treatment delivered when a disease state arises, proactively resolving issues around providers who don’t participate is key to keeping Medical Record Retrieval projects healthy. Record retrieval vendors should have the following capabilities:

  • Immediate Notification of Nonparticipating Providers
    Payers need up-to-date, thorough and accurate data that includes reasons for non-participation; details around the last correspondence with each provider; and location history, among other details.
  • Collaborative Workflow Tool to Solve Noncompliance
    Being notified of non-participating providers isn’t enough. An efficient mechanism leveraging technology is key to enabling payers and a vendor’s OCs to collaboratively and seamlessly resolve issues or prioritize nonparticipating providers. Sometimes health plans absolutely want to continue reaching out to providers, other times contact will be discontinued.
  • Workarounds
    Through the above capabilities, payers can determine in a timely manner whether additional efforts are needed to meet project goals (i.e., provider offices must be added to a project). This is crucial if a payer decides to halt retrieval efforts at certain offices due to noncompliance.

Like preventive medicine strategies, best practices exist to ensure that non-participation doesn’t imperil medical record retrieval. Ensuring that a medical record retrieval vendor can implement these best practices is one of the smartest moves a payer can make.


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Presentation @ RISE VBC: Effective Collaboration Strategies Between Payer & Provider