4 Reasons for Medical Record Requests and How They Can Affect Providers

A smiling doctor crossing his arms with a blurred patient and nurse in the background reviewing a medical record.
Blog Posts  |  27 July 2021

More than 100 million medical record requests are made to healthcare providers every year.1 Despite the widespread use of electronic health record (EHR) systems, 90% of those requests are fulfilled using manual methods such as traditional paper, mail, or analog fax.1-3 Retrieving medical records manually costs practices hours of staff time, particularly because all medical records must be handled according to the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).4 Volumes of chart retrievals divert precious resources from where you really want them—supporting patients.5

With the rise of the COVID-19 pandemic, many providers experienced a temporary lull in medical record requests. Commercial and Medicaid medical record requests for Healthcare Effectiveness Data and Information Set (HEDIS®) reviews and for Medicare risk adjustment reviews continued during the pandemic without interruption. However, the Centers for Medicare and Medicaid Services (CMS) and most other payers suspended other audit and review-related medical chart requests to allow healthcare providers to focus their time and energy on patient care. Now that the COVID-19 public health crisis is improving, though, experts predict an upswing in medical record requests. In fact, providers are starting to see more requests already. Commercial requests for medical records for audits and risk adjustment reviews have resumed; medical record requests for quality reviews have also been reinstated.6

In this article, we outline the primary reasons why healthcare providers (HCPs) are asked to submit medical records for review and share how Veradigm can help automate this otherwise lengthy and onerous process.

Why do HCPs have to submit medical records for review?

1. Supports appropriate reimbursement

Medical record retrieval is an important service for payers. One reason is that health plans need to retrieve member medical record data to support appropriate reimbursement.3 Payers may request a medical record to access information to help them process an existing claim. They may also request medical records for a claim audit.7

An audit may be prompted by data analytics that identified the provider as an outlier in some respect. Payers use data analytics to look for potential overpayment cases. In this situation, the payer may be looking to recoup payment for an improper claim, or they may hope for reimbursement on a claim that was overpaid.7 Failure to respond to this type of medical record request can create a situation in which Medicare suspends a future payment, or a commercial payer demands reimbursement for a claim they believe was overpaid.8

However, not every medical record request is related to an audit.

2. Quality assessment and reporting

Medical record retrieval is also used to collect data for HEDIS measures and for the CMS 5-Star Rating System, two systems used to assess and report health plan quality.2

What is HEDIS?

CMS contracted the National Committee for Quality Assurance (NCQA) to develop a strategy for evaluating the quality of care provided by health plans. NCQA developed HEDIS, a set of standardized performance measures, to assess this quality of care. HEDIS measures allow consumers to compare health plans objectively, “apples to apples.”9, 10 Health plans use HEDIS measures to see where they are performing well in the services and care they provide to their members and where they need to improve.10

Although not all health plans or payers need to submit HEDIS results, it’s required for all Medicare Advantage plans and most Medicaid plans. According to the NCQA website, 190 million people are enrolled in plans that report HEDIS results every year.10

How HEDIS results are used

HEDIS results are used in multiple ways. Health plans can use HEDIS performance data internally to:9

  • Identify potential areas for improvement
  • Track improvement
  • Measure the success of quality improvement efforts
  • Provide standards to allow comparisons between plans

HEDIS performance results are also publicly available. They are used for reports that rank and compare the quality of different health insurance plans, such as the U.S. News and World Report’s annual “Best Insurance Companies” report.10

NCQA also offers Health Plan Accreditation, which is partially based on HEDIS results. NCQA Health Plan Accreditation is an evidence-based recognition that is dedicated to measuring and improving the quality of health insurance programs.11

3. CMS Five-Star Quality Rating System

For Medicare Advantage plans, HEDIS results are used to help calculate CMS Star Ratings. For the CMS Star Rating System, plans are evaluated and rated with one to five stars. Four-star and higher plans receive additional quality bonuses. Five-star plans gain the advantage of being able to enroll members year-round. They are also able to offer their members more benefits, giving them a competitive advantage. Low performing plans, on the other hand, may be fined and, if they don’t improve, can lose their CMS contracts.10-12

HEDIS results can lead to significant changes in CMS reimbursement to payers; millions of dollars in incentive payments may be at stake.10

How the CMS Star Rating System can impact healthcare providers

The CMS star rating may apply directly to health plans, but a health plan’s rating can benefit associated providers as well. The star rating system encourages health plans to support a greater focus on preventive medicine and early disease detection. Plans with higher star ratings also tend to have strong benefits supporting management of chronic conditions.12, 17 As a result, a higher star rating may mean you can help your patients experience better health.13

In addition, many health plans have programs offering education, tools, or bonuses to help providers meet specific quality measures.13-15 Similarly, provider encouragement programs actively reward clinicians who work with health plans to reach out to members, close care gaps where needed, and make sure to maintain detailed health records for their patients.16 Working with payers to meet these goals can increase the quality of care offered by your practice while simultaneously generating additional revenue.13

The star rating system puts health plans and providers on the same team, working toward a common goal of increased patient satisfaction, high quality care, and the resulting higher star rating.13

How providers can influence star ratings

Providers and practices can have a significant impact on a health plan’s star rating, because their star ratings are directly influenced by the quality of care providers deliver to their members.13, 17 As a result, when health plans achieve a higher star rating, they frequently pass on a portion of their additional revenue to their providers via rate increases or incentives for providers that deliver high quality care. Similarly, Medicare Advantage plans are designed to reward practices that specifically focus on delivering high quality care.13

4. Risk adjustment reviews

Payers also request medical records to be used for risk adjustment reviews. Risk adjustment reviews originate from Medicare Advantage, Medicaid, and commercial health plans.18 They are used to reallocate funds from payers whose members are lower risk (and, thus, lower cost) to payers with members who are higher risk (and, thus, higher cost.)7

What is risk adjustment?

CMS defines risk adjustment as a process used to predict the future health care expenses of individual plan members based on their medical diagnoses and demographics.19, 20 Risk adjustment is a statistical process used to assign a “risk score” to plan members based on their health conditions, health status, and demographics. The risk score is then used to predict the cost of providing healthcare for that person.20-22 For example, a patient who has type 2 diabetes and high blood pressure will be assigned a higher risk score than a healthy patient.19

CMS uses risk adjustment to adjust payments to health plans based on their plan members’ risk scores.22 In general, health plans receive higher payments for sicker patients and lower amounts for healthier patients.19, 22, 23 For instance, a health plan will be compensated more for covering the patient with type 2 diabetes and high blood pressure than they will be compensated for the healthy patient.19

Correctly calculating risk scores requires review of members’ medical records. It also requires those records to be complete, accurately capturing the appropriate diagnosis codes for each member. Inaccurate diagnoses may cause CMS to pay health plans inappropriate amounts.22, 23

How risk adjustment reviews can benefit providers

Risk adjustment reviews influence the payment amounts health plans receive for their beneficiaries, but they can also benefit providers. First, providers benefit simply from reviewing their patients’ medical records. This process helps providers better understand their patients’ full spectrum of health conditions so they can better manage patients’ health care. Second, review of medical records can help reveal undocumented, inaccurate, or missing diagnoses, which can interfere with patients receiving appropriate care.19

Finally, some health plans incentivize providers for their assistance with medical record retrieval for risk adjustment purposes.19, 22

Automated medical chart retrieval

Performing medical chart retrievals is an essential task. It is also one that carries a host of risks if you fail to comply. HEDIS quality reviews and risk adjustment reviews can make differences of millions of dollars to payers.7 That money can affect the benefits available to your patients, the potential size of your patient pool, and, ultimately, your revenue.13 If you fail to retrieve a medical record when the payer is performing an audit, that gives the payer the right to rescind payment on the associated claim.8 For all types of requests, failure to retrieve medical records in a manner that safeguards your patients’ protected health information can result in a data breach and HIPAA penalties.24

However, there is a way to streamline medical record retrieval requests: Veradigm® eChart Courier™. Veradigm eChart Courier enables you to save time, cost, and resources by retrieving medical records electronically rather than manually.2

The typical method of medical chart retrieval involves searching for charts individually and manually delivering them—mailing or uploading via web portal—to the requesting company. This process is expensive and time-consuming. eChart Courier was developed with the goal of eliminating these manual chart retrievals, allowing you and your staff to focus on patient care.2, 25 At the same time, you can still support data collection for NCQA, HEDIS, and CMS Star Quality reports.2, 25 eChart Courier also delivers information in an encrypted format. Only intended recipients can unencrypt the data, ensuring compliance with applicable HIPAA rules.2

Veradigm eChart Courier and your practice

If you are currently using Allscripts Professional, Allscripts TouchWorks, Practice Fusion, or NextGen EHR, you can enroll in eChart Courier for free.

After your enrollment, participating health plans, aggregators, and life insurance companies will be able to request medical records through Veradigm eChart Courier. Veradigm eChart Courier matches patient information to ensure that medical record data is pulled for the correct patients. Clinical data is then returned to the requestor in a secure, encrypted format. Providers have access to reports detailing which medical records were retrieved and which company requested them.25

If you are spending time diverting resources from patient care to satisfy a stream of requests from health plans, life insurance companies, and more, Veradigm eChart Courier can help you to handle these requests more efficiently

Click here to learn more about Veradigm eChart Courier and how it can help your practice to operate more efficiently.


  1. Technologies S. Allscripts Milestone Points to Industry Shift to Streamlined Records Processing. ScanSTAT Technologies. Updated April 28, 2017. Accessed June 24, 2021, https://www.scanstat.com/industry-shift-streamlined-records-processing/.
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  3. Medical Record Retrieval. COTIVITI. Updated 2021. Accessed June 23, 2021, https://www.cotiviti.com/solutions/risk-adjustment/medical-record-retrieval.
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  9. Healthcare Effectiveness Data and Information Set (HEDIS). CMS. Updated January 5, 2021. Accessed June 21, 2021, https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS.
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  11. Health Plan Accreditation FAQs. NCQA. Updated 2021. Accessed June 26, 2021, https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa/faqs/.
  12. CMS STARS Rating System Overview. Accessed June 25, 2021. https://healthcarela.org/wp-content/uploads/2016/12/CMS-STARS-Rating-System-Overview-3.doc.
  13. Zheng J, Coffin J. Improving quality and increasing star ratings. Medical Economics. Updated March 18, 2020. Accessed July 13, 2021, https://www.medicaleconomics.com/view/improving-quality-and-increasing-star-ratings.
  14. Total Health Care Integration with Priority Health. Total Health Care. Accessed July 14, 2021, https://thcmi.com/priority-health-integration-information/.
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  17. What Are CMS Star Ratings? Accessed June 25, 2021. https://www.bcbst.com/docs/providers/quality-initiatives/What_Are_CMS_Star_Ratings.pdf.
  18. Ford G. The Rising Tide of Payer Requests for Medical Records: How to Shore Up Your Defense. MRO. Updated May 30, 2021. Accessed June 24, 2021, https://mrocorp.com/blog/mro-webinar-recap-rising-tide-of-payer-requests-for-medical-records/.
  19. Risk adjustment. Priority Health. Accessed June 27, 2021, https://www.priorityhealth.com/provider/manual/billing/risk-adjustment.
  20. Welling R. Beware of risk adjustment practices that could put your health plan at risk. COSMOS: Compliance Today. Updated March 2021. Accessed June 27, 2021, https://compliancecosmos.org/beware-risk-adjustment-practices-could-put-your-health-plan-risk.
  21. What Is Risk Adjustment? American Academy of Professional Coders (AAPC). Updated March 8, 2021. Accessed June 26, 2021, https://www.aapc.com/risk-adjustment/risk-adjustment.aspx.
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  23. Medicare Advantage Risk-Adjustment Data–Targeted Review of Documentation Supporting Specific Diagnosis Codes. U.S. Department of Health and Human Services (HHS) Office of the Inspector General Accessed June 27, 2021, https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000422.asp.
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  25. How to enroll in Veradigm eChart Courier™. Veradigm. Updated 2021. Accessed June 22, 2021, https://veradigm.com/get-started-with-echartcourier-practice-fusion/.  
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