Risk Adjustment Audit?


I would like to take the opportunity to use the new and improved Washington Psychologist to catch us all up on some subjects about which I receive a lot of questions. First on the list: risk adjustment audits. A number of WSPA members have received letters requiring them to undertake RA audits. These are different from traditional audits that focus on issues such as medical necessity, provider record keeping and the like. Most importantly, these audits do not result in retroactive denial of reimbursements.

Requirements of RA audits are spelled out in the Affordable Care Act (ACA). With passage of the ACA, millions of previously uninsured people are now able to purchase health insurance. The intent of the RA audits is to keep insurance plans with more unhealthy enrollees competitive with plans with healthier enrollees. More funds will flow to plans taking more risk (less healthy enrollees) from plans taking less risk, according to the ACA.

As of 2015, insurance companies are now required to randomly sample the patients they insure through these audits in order to assess overall population health and to ensure that the risk adjustment dollars moving from one plan to another are based on reasonably accurate patient data. In a two-step process, insurers sample the enrollees they cover, report that data to HHS, which then samples a random selection of those audits.

All providers who have current contracts as network providers with insurance companies are required to participate. If you have read your current contract carefully (as your trusty DPA urges you to do), you may have read this clause.

How will you know when you receive an audit notice that this is an RA audit? Some will clearly mention that the audit you are being required to complete is for risk adjustment purposes or will state that the audit is required under the terms of the ACA. According to the APA Practice Organization (APAPO) some notices just refer to the program as “data collection” instead of “audit.” Typically, in our state insurers have requested the treatment records of up to three patients for a specific period of time (again, typically in Washington State this has been a calendar year). If you are unclear about the specific intent of the audit, contact the insurance company and ask.

WSPA recommends that you then take the following steps:

1. Determine that you have necessary patient consent before proceeding. We suggest that you discuss the audit with your patients even though by using their insurance card, patients authorize release of information to their insurance company for payment purposes. However, some insurance companies may not include information (yet) about authorizing release of records for purposes other than payment. If you do not use the consent form recommended by the APA Insurance Trust (APAIT) found on their website (www.apait.org), you should have your patients whose records will be audited sign a release of information form and make sure it is also dated.

2. Be clear about which records to provide. Remember that “psychotherapy” or “process” notes, your informal notes if you keep them, are separate from the treatment record and are specifically exempted from release by HIPAA regulation. The treatment record that must be released should contain: all session notes, dated with start & stop times; a summary of symptoms, diagnoses, functional status; treatment plan, progress (or not) to date, results of tests, medication information and treatment modalities.

If you complete outcome testing, that should also be included. If you keep a combined record (ie, your process notes are part of the treatment record) you can and should extract that material from the record you send to insurers. The rule of thumb here is to release the “minimum necessary” material.

3. If you have questions about the RA audit process, always ask them of your contact at the insurance company (or the contractor doing the work for the insurer). In recent RA audits in our state, a few patients have refused to release their record. When this has occurred, the psychologist contacted the insurer and asked to replace that patient or to simply release the other requested patient records, and the insurers have agreed. Additionally, always ask if there are deadlines for providing the materials, and always ask for an extension if you need one (we all get sick or go on vacation).

4. Feel free to call/email your trusty DPA. There are no stupid questions! Remember, I can’t help you if you don’t contact me. lucy.homans@gmail.com

Thank you.