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Risk Adjustment Letters - 12-16-15

16 Dec 2015 12:00 PM | CSWA Administrator (Administrator)

Dear CSWA Affiliated Society Members,

Here is some information on the letters you may be getting from insurers asking for patient records. These requests are not the usual treatment review requests if they have the term “risk adjustment” as the reason for the request.  Most insurers are hiring an auditing firm to collect this information. Regence BlueShield is using AventMed, for example.  Here is why.

When the Affordable Care Act was created, Federal regulators set up a Risk Adjustment Program to keep insurance plans with unhealthy patient populations competitive with plans with healthier populations for whom care is less expensive. The Risk Adjustment letters are the assessment of this goal. The first time insurers were required to ask for this information was in November, 2015.

Some insurers are asking for the “full chart”, a statement that has created confusion. What is being requested is the Medical Record. As you know, if you do not limit the information you include in the Medical Record, you need to submit the whole record, even though it is likely to be far more information than the insurer wants.

Though it is more work, it will provide much more confidentiality to patient information to have dual records, i.e., to have a Medical Record with basic information, treatment goals, and treatment progress and Psychotherapy Notes as the record of any detailed process notes.


Below is a summary of what must be included in the Medical Record and cannot be shielded by Psychotherapy Notes.

Medical Record Template – 12-11
Laura Groshong, LICSW, CSWA Director, Government Relations

 From HIPAA Seven Years Later: The Impact on Mental Health Practice, Groshong, Myers, and Schoolcraft (2011, p. 17): According to HIPAA Rules, the Medical Record should include, as applicable:

  • Intake information;
  • Billing information;
  • Formal evaluations;
  • Notes of collateral contacts;
  • Records obtained from other providers;
  • Counseling sessions start and stop times;
  • The modalities and frequencies of treatment furnished;
  • Medication prescribed, if known;
  • Any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and
  • Progress to date.

Outcome tools may be required in the future to document progress in mental health treatment.

Psychotherapy Notes: If dual records are kept of the Medical Record and Psychotherapy Notes, i.e., process notes, the process notes are not part of the Medical Record. If there is one record, process note are included in the Medical Record.

I hope this helps in your responses to these risk adjustment requests.

PO Box 10, Garrisonville, Virginia  22463 | administrator@clinicalsocialworkassociation.org

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