Risk Adjustment

Data Management: Key to Overcoming Low Medical Record Retrieval Rates

Medical record retrieval, a vital element of risk adjustment programs, is also one of the most challenging areas for payers. A labor-intensive process, record retrieval requires significant time, resources and perseverance (particularly when the proper vendors and best practices are not in place). Add in stringent CMS submission deadlines, and retrieval targets become that much more difficult to hit.

To be a front-runner in terms of retrieval rates, payers must not overlook back-end retrieval processes. Efficiency is an absolute must, especially when it comes to overcoming the hurdles that stand in the way of actionable, clean “chase” data (member and provider information).

Examples of these barriers (i.e., data that must be fixed, clarified or found) include:

  • billing provider addresses that are different from rendering providers’ (when addresses differ, the billing provider will not have the documentation)
  • incorrect addresses, phone numbers and fax numbers
  • when providers see patients at more than one clinic (address to which request must be sent needs definition)
  • when a practice’s doctors are not bundled (bulk request is ideal to individual requests to each provider)
  • when a provider moves, retires or dies and thus location of records needs to be determined
  • provider linked to a member needs to be determined (when a member sees various providers within an office)
  • no on-file PCP for a member (providers are not within network’s locations)

A comprehensive data intake and analytics process is crucial for both effective outreach as well as for obtaining the highest possible medical record retrieval rate. When assessing medical record retrieval vendors, payers should look for those whose data intake and analytics capabilities boast the following attributes: Chase List Optimization, Provider-Network Depth and a Strategic Approach to Resolve Noncompliant Providers.

Chase List Optimization

Starting a chase as early as possible is common sense strategy. And yet, with data accuracy affecting the ability to locate, retrieve, and code charts, data risks must first be identified up-front and missing data corrected ASAP.  When surveying potential vendors, payers must look for vendors who can:

  • identify and report to payers incorrect, missing, poorly formatted and damaged data components (examples above) through data integrity and validation checks
  • research correct info and, if payer prefers, fix errors on the plan’s behalf, freeing up significant time for other efforts

Provider Network Depth

Payers should also consider the depth of prospective vendors’ provider network databases. Making sure a vendor has established relationships with a variety of provider groups (and copy services) is a smart move, as it helps ensure a rich provider database of physician sites. This is especially useful in the data cleansing process described above.

With a deep provider database, a retrieval project will already be one step ahead, with fewer errors to fix, given the automatic decrease of the grueling legwork required when there’s a dearth of provider data. Also, payers may want to consider that a vendor may still lack provider depth in an area that’s vital to a plan. Payers shouldn’t shy away from scrutinizing a vendor’s provider network in a key region or market. 500,000 East Coast providers aren’t going to boost Midwestern retrievals.

Strategic Approach to Resolve Noncompliant Providers

The most successful retrieval projects are those in which a health plan’s network management team collaboratively partners with a vendor from the start to manage nonparticipating providers. That’s why it’s vital that payers also consider how strategically a vendor can utilize its data, especially when gleaning historical information around providers who, for example, rarely submit requested charts. Rather than wasting time making a second or third call to these providers, vendors can designate specialized teams to build a strategy around Providers-Not-Participating (PNPs) to avoid impact or delays to chart recovery efforts. Picking a vendor that strategically customizes how to approach historically noncompliant providers can help ensure a project’s success and the highest possible retrieval rates.

Medical Record Retrieval is hard. But it doesn’t have to be. Payers can mitigate retrieval pain points by:

  1. Get a head start using the previous year’s data and gleaning “lessons learned,” which will create a strong foundation for the current year’s chart retrieval process
  2. Ensure that said foundation includes:
    • data scrubbing
    • “teams” to work with the Plan for providers who had issues in the previous year
    • weekly meetings to discuss issues and trend the retrieval rates
    • working with the Network Development team to obtain correct location information
    • establishing expectations on all aspects of the program, particularly around obtaining records from providers who do not want to participate; payment parameters for the records; and escalation procedures when there are issues obtaining charts

Through a team approach that duly considers the above points, vendors and health plans will make strides toward ensuring the success of any chart retrieval project.


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