2/13/15 Horizon/EMSI Records Requests

The ANJC has received information from membership that Horizon BCBS of NJ has hired an outside consulting firm, EMSI/Leprechaun, to perform a record review of chiropractors for what it purports to be a Commercial Risk Adjustment Review.

Examination Management Services, Inc. (EMSI) is a medical information, risk management and investigative service, which acquired Lep Med, Inc. (doing business as Leprechaun), a provider of risk identification and adjustment services to Medicare Advantage health plans and related industries in August 2012. Leprechaun pioneered the use of clinically based algorithms to identify members whose risk adjustment scores do not reflect their actual diagnoses. Commercial risk adjustment was established as part of the Affordable Care Act to stabilize risk for individual and small group plans inside and outside of the Exchange marketplace. It helps carriers offer various plans to meet the needs of a diverse population and is administered either by individual states or by the Department of Health and Human Services.

The ANJC has received numerous calls from members concerning this record request and provides the following guidance. This guidance is being provided as informational only and is based upon the information that we have received to date which may change as new information is received. The ANJC will keep membership advised as any new information is received.

1)  Do I have to Respond to this Request for Records?

Participating Providers: If you are a participating provider with Horizon, you have signed a participating provider agreement wherein you have agreed to provide copies of records upon Horizon’s request at no charge within 20 days of the request. Thus, par providers have a contractual obligation to respond to the request.

Non-Par Providers: If you are not a participating provider, you have no contractual obligation to respond but failure to respond could result in Horizon denying your claims or opening up an official audit of your practice. This review may also be mandated by federal law. Thus, it is our recommendation that you do not ignore this request and respond per this advisory.

2)  How Long Do I have to Respond?

Participating Providers: If you are a participating provider with Horizon, recent amendments to your participating provider agreement require you to provide copies of records within 20 days of receipt of the request. If the EMSI / Leprechaun request has an earlier deadline, contact them and indicate you have 20 days to respond under your agreement and obtain an extension.

Non-Par Providers: If you are not a participating provider, New Jersey Chiropractic Regulations require you to provide copies of records within thirty (30) days of receipt of a request from a third party. N.J.A.C. 13:44E-2.2. New Jersey regulations also permit you to charge $1 per page for up to $100 maximum for the entire chart. N.J.A.C13:35-6.5.

3)  How Far Back Can they Ask for Records?

Par & Non-Par Providers: The New Jersey HCAPPA, NJSA 17B:30-48, permits carriers and their agents to review records in post payment review for up to 18 months from the initiation of the review. However, if the carrier identifies fraudulent billing or an inappropriate pattern of billing, they can go back a full six (6) years. It is our opinion that, as the record request does not identify an allegation of fraud nor inappropriate billing and specifies in bold that “Please be assured this is not an audit,” that the 18 month look back would apply and you only have to provide records for 18 months prior to the date of the record request.

4)  What if I have Concerns About the Record Request and My Records?

If you are concerned about this request for records or about your documentation or recordkeeping specific to your practice, we advise that you contact a health care attorney prior to responding to the request to discuss your specific situation. The ANJC cannot give legal advice on specific situations.

As of right now, this appears to be a record review for data gathering purposes only. However, please be aware that the results of this review could be a precursor to an audit if improper billing and documentation is revealed on the part of a provider. As new information is obtained, the ANJC will keep membership apprised.

If you have any specific questions in this regard, please contact Matt Minnella, ANJC’s insurance director at matt@anjc.info.

Very Truly Yours,
Jeff Randolph, Esq.
General Counsel to the ANJC