Planning and preparing for requests for clinical documentation from health plans can be extremely difficult from an operations perspective. While managing year-round requests to support denials, audit and second-level appeals, the arrival of the seasonal quality-measure and risk-adjustment requests can easily catch organizations off guard. Request timing is a challenge on two fronts.  First, the arrival timing is largely unknown until the requests are on the door step, and second, the window to respond is now shorter than ever. To make matters worse, the 2018/2019 season is proving to be a record year for request volume increases, which will only serve to further exacerbate existing timing challenges.

What is coming?

As the industry leader in clinical documentation management, Ciox has unique visibility into the expected volume of requests, and recently we gained more insight to the 2018/2019 season. Typically, the volume of Medicare Risk Adjustment (MRA) and HEDIS requests tends to increase 20-30% from one year to the next. This year, those numbers are expected to TRIPLE! Requests for MRA are expected to increase 60-70% over 2017 and 2019 HEDIS volumes are expected to be 100% greater than this year.

You might ask “Why are health plans asking for so many records?” I wish I had a nice easy answer but unfortunately the reasons vary greatly from quality scoring to risk adjustment, and volume is also affected by the steady growth in Medicare Advantage enrollment. Enrollment in MA has steadily increased from 5.3 million beneficiaries in 2005 (comprising 13 percent of the population) to 19 million in 2017 comprising 33 percent of the population).[1]

Regardless of the reasons, we know one thing for sure – the number of requests is going to continue to increase, and providers need to identify ways to effectively manage not just their health plan requests, but their core release of information (ROI) and patient requests as well.

How can you meet the coming demand?

Given the variety of operating models and disparate infrastructures that are in place within and across provider organizations, the expected growth in the volume of records requests can be daunting. However, there are measures you can take to get ahead of the expected health plan volume (HEDIS/MRA) and ensure you don’t experience any negative impact on your core ROI and patient requests.

We asked some of our customers what they felt was the most feasible and flexible model to provide the needed support for these requests. The clear majority agreed – remote access to fulfill requests is critical. Remote connections allow for on-site staff to be augmented with a remote team fulfilling large volume requests from health plans without impacting other ROI requests.

When implementing a remote retrieval model, whether internally or with a partner like Ciox, be sure to consider the following:

  • SECURITY: Make sure your remote solution meets the highest security standards, such as SOC II, Type 2 compliance as well as HITRUST certification requirements.
  • CONNECTIVITY: When working with an external partner, ensure they use proven, standards-based connectivity methods that can work with your existing technology infrastructure, allowing your IT teams to leverage existing investments and greatly simplify the setup.
  • PAPER RECORDS: Paper records are still a major part of healthcare today so be sure your model includes a process for managing retrieval of paper records. These requests can be handled by on-site teams to allow remote resources to focus on electronically accessible requests.
  • COST: There should be no significant cost for implementing a remote model and when working with a vendor partner, the cost of implementing the solution is typically absorbed by the vendor. In short, the only cost comes from not acting as soon as possible.

The volume and timing of health plan requests for medical records are out of your hands, but with some planning and an effective model for handling both paper and electronic records, you can ensure these volumes are managed efficiently and that you can continue to deliver excellent service to all your requestors.

Are you ready for the upcoming tsunami of requests? Partnering with an industry leader like Ciox can offer you the expertise, technology, and flexible scalability to successfully meet the growing demand for medical records.

Ready to learn more about how Ciox can help your organization ensure timely response to health plan requests? Do you have questions about specific health plans? As a leader in medical record retrieval services, Ciox is proud to have connections with over 100 health plans across the country and can work with you to prepare for and successfully manage your health plan volume.


[1] SOURCE: Kaiser Family Foundation’s analysis of SMS Medicare Advantage enrollment files, 2008-2017, and MPR Tracking Medicare Health and Prescription Drug Plans Monthly Report, 1999-2007. Source cited in Life Science Leader, “Medicare Advantage: The Solution To Value-Based Care”

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