How to Respond to ACA-Mandated Requests

A number of members have recently called APA’s Practice Management HelpLine about requests they’ve received from insurers for documentation of patient care in the past year. The HelpLine received a spate of these calls last year, and now they have begun to come in again. Some members are in-network providers, while others have no contractual relationship with the requesting insurers.

The letters note that the request is being made in response to a requirement of the Affordable Care Act (ACA) that insurers who provide care under the ACA show that they are reviewing a percentage of their claims to ensure that they are accurate. The letters do not suggest that providers are required to produce records; they also do not cite particular contract provisions requiring compliance or represent that patients have given permission for the release of their records. We believe that insurers (or the companies they have hired to carry out the reviews) send these requests to all providers who have filed a claim for one of their beneficiaries, regardless of whether the providers are in network or not, with the notion that sending a flood of requests will yield enough responses to fulfill the ACA requirement.

What can you do? We’ve found that when APA members call the requesting company at the phone number supplied in the letter, explain that they are a psychiatrist with concerns about confidentiality, and note that permission must be granted from the patient before any information is released, they are told not to worry about submitting the documentation at the time of the call; they may, however, be contacted later if the information is required.

If a phone call does not resolve the issue, you can use this form letter that APA has developed for this purpose:

If you have further questions about this issue, please contact APA’s Practice Management HelpLine at (800) 343-4671 or [email protected]. ■