The following information has been provided with permission from Stacie Saylor, CPC:
Background
With the passing of the Medicare Modernization Act (MMA) of 2003, the Centers for Medicare & Medicaid Services (CMS) initiated the formal implementation of a fully risk-adjusted capitation reimbursement model. As a result, all Medicare Advantage (MA) Plans are ultimately financially dependent upon the specific documentation of each individual patient's diagnoses as classified within the highly specific CMS Hierarchical Condition Category (HCC) system. Failure to do so has both significant quality of care implications and financial ramifications. As a result, MedAssurant undertook an evaluation of more that 1,000,000 Medicare Advantage unique member/date-of-service period cases from its client base in an effort to identify primary causes and methods of efficiently correcting for incomplete claims and claims-related diagnostic documentation.
There are many payers in Michigan who are conducting the medical reviews mentioned in the paragraph above. MSMS has learned that Blue Cross Blue Shield of Michigan (BCBSM), Blue Care Network (BCN), Aetna, Humana and Molina currently are asking for medical records through MedAssurant. MedAssurant is only a data collection company that is contracted by the individual payers. Humana also is using a company called MediConnect to collect data. They use MediConnect for the smaller volume review and MedAssurant for the higher volume reviews.
Medical Review Compliance
There is a great deal of confusion on whether compliance with the reviews is mandatory. CMS has told MSMS that physicians need to review the terms and conditions in any Medicare Advantage contracts they may have. Keep in mind that these are medical reviews and not financial audits. If the contract is not clear on the medical reviews, you may want to contact the plan for clarification. BCBSM has told us that the medical reviews are voluntary for their MA plan(s). Humana has indicated that compliance is required for the Humana MA plan(s). If a physician is contracted with Cofinity, then the medical reviews for Aetna's MA plan(s) are required. MSMS cannot confirm that BCN and Molina's policy on compliance at this time; however, if you do have a contract with either of these payers for their MA plan(s), please review the terms and conditions of that contract.
Reimbursement for Medical Records
BCBSM will reimburse physicians $3.00 per record. You must fax a reimbursement request to 800-431-9451 or email it to marevenuemgtops@bcbsm.com. Include the name of the person or facility the check should be made out to; address where the check should be sent; the number of records requested by MedAssurant and the number that was submitted; and site ID number. You should receive your check in about three weeks.
For non-contracted physicians, Humana will reimburse the physician per the state guidelines for copies of medical records. Physicians can send an invoice with the medical records.
Aetna has no set fees for the medical records collected for medical reviews. Aetna is willing to work with the physician to pay what is reasonable and customary.
MSMS does not have reimbursement information for BCN or Molina at this time.
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organization and please feel free to contact us with any and all questions you have regarding MMBA. 
