BC Advantage - 2013 Issue 2
A Tale of Two Data Sources: Why Health Plans Must Conduct Retrospective Medical Record Review
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Article Overview
This article explains the difference between the information captured on medical claims and the information health plans need for HEDIS and risk adjustment work. It is aimed at providers, coders, and health plan staff who want to understand why retrospective chart review is sometimes necessary, how the process affects practice operations, and how planning can reduce disruption.
Why This Topic Matters
Understanding the limits of claims-based data helps practices and health plans coordinate documentation requests, support regulatory reporting, and reduce avoidable workflow burden. The topic is relevant to organizations working with HEDIS and CMS-related risk adjustment requirements.
Article Sections
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The Variation in Information is Systemic and Currently Not Preventable
Discusses why claims data and medical record data serve different purposes and why the information available to health plans may differ from what appears on a claim. The section also addresses the general need to align data sources with regulatory requirements.
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Limiting the Intrusion
Covers ways health plans and their representatives may reduce disruption when requesting and reviewing records. The section focuses on operational approaches to limit unnecessary visits and staff burden.
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Will it Always Be This Way?
Addresses the longer-term challenge of aligning provider and health plan payment and data needs. The section looks at collaboration and workflow improvement at a high level.
What You Will Learn
- Why claims data may not fully support health plan quality and risk-related needs
- Why retrospective medical record review is used in some health plan workflows
- How chart-request processes can affect physician practice operations
- What broad strategies may reduce inconvenience during record review
- Why cross-industry alignment is discussed as a long-term goal
Who Should Read This
- Physician practices
- Medical coders
- Health plans
- Quality reporting staff
- Risk adjustment teams
- Compliance and operations professionals
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