Provider Notices

CCMA Medical Record Review

8/22/2008 9:50:19 AM

Below is a copy of the Medical Record Review letter that was sent out to our contracted provider offices.  If you have questions, please see the contact information below.  Thank you. 


Action Item: Clear Choice Health Plans Medicare Advantage Medical Record Review By Cognisight, LLC

Given normal physician and hospital billing workflow, many chronic diagnoses may not be submitted on claim forms but are documented in the member’s medical record. The Centers for Medicare & Medicaid (CMS) requires that evidence of each submitted diagnosis exist within the medical record pursuant to a physician-patient encounter and be signed by the treating physician. If existing diagnoses are not captured and submitted to CMS, payments by CMS to Clear Choice Health Plans will not accurately reflect the patient’s complexity of care. This does not imply that there are any errors in your normal coding practices. CMS has created a reimbursement formula that requires information not normally available or expected in normal claims processing and must be attained via a medical record review of individual member diagnoses that were treated or impacted.
CMS recognizes this difference and encourages physicians to document ICD-9-CM diagnoses. CMS also gives guidance to payers in helping physicians who care for member’s to review existing medical records for documentation of a relevant diagnosis. In addition, where medical records are reviewed after the payer’s initial submission of diagnosis information, CMS allows the payer to revise its diagnosis submission, so long as the submission is made within certain time limits.
As a result of analysis, we have identified indications of other valid diagnoses for patients under your care. A targeted medical record review will be performed to collect any diagnoses that were documented in the medical record but not submitted on a claim form in the year 2007. 
Clear Choice Health Plans has engaged Cognisight, LLC to manage and support gathering of complete diagnostic profiles for Clear Choice Health Plans Medicare Advantage Plan members. These efforts began with analyzing member claims data to determine what diagnoses were submitted, whether evidence of additional diagnoses actually exists based on prior years’ claims, and what other diagnoses would be expected from ancillary documentation in the medical record. 
Your office will be contacted to schedule a review over the next several weeks. Enclosed is a list of the Clear Choice Health Plans Medicare Advantage members under your care in 2007 for which we have found indications of additional, existing diagnoses.
Upon this visit, a nurse/auditor will be reviewing your records and documenting as required. They are there to audit and to assist in the process in any way you find helpful. We are happy to audit your records at your preferred location(s). We would like to have the chart review process for the entire, selected Medicare Advantage population completed by the end of September, 2008 to accommodate CMS deadlines for data submission. 
Clear Choice Health Plans will not criticize or score physicians on their coding, this effort is provided only to collect the patient diagnoses that apply to the CMS payment methodology.
Clear Choice Health Plans recognizes that this effort will take considerable time on your part and on the part of your office staff. Accordingly, under our new relationship with Cognisight, you will be reimbursed $25.00 for each medical record requested, whether or not any additional diagnosis is found. We believe the payment is a fair market value for your time and is not contingent upon finding any additional diagnoses. 
Within one month of our receipt of the completed audit, and the return of the completed (enclosed) W-9 form, you should expect a cumulative payment of $XXXX.00 in recognition of your costs in providing us this access. Please refer to the attachment for instructions and additional information regarding the reviews. 
Thank you for your cooperation in accomplishing this effort. Every effort will be made to minimize disruption to your office. Should you have any questions or concerns regarding the medical record review please contact Cognisight Account Manager: Tom Cummings at (585) 281.8282 or Manager of Administrative Services Jenn Doran at (877) 271-1657.
Clear Choice Health Plans, Inc. 
Please retain the enclosed list and share with your staff to prepare for the chart review. Should you or your staff prefer that the list be sorted or segmented differently, please call Cognisight at (877) 271-1657, and a new list will be prepared.
A representative of Cognisight will be calling to schedule your chart review. (At that time a duplicate patient list may be faxed to your office at the request of your staff.)
·        All chart reviewers will have identification badges
·        All chart reviewers have received HIPAA training
·        Please call the Cognisight Account Manager available to you by phone or in person if you have any questions or require further support.
·        Contact Information for your Account Manager:
                                                               i.      Tom Cummings – (585) 281-8282
                                                             ii.      Jenn Doran – (877) 271-1657 (Manager of Administrative Services)