A Tale of Two Data Sources: Why Health Plans Must Conduct Retrospective Medical Record Review  

Category: Practice Management

By Dustin Goossens

It's a Tuesday afternoon and your phone is ringing. It's been a crazy day with a large influx of patients, mounting paperwork, and constant interruptions. You answer the phone to hear a representative from one of your health plans on the other end of the line, wanting to arrange a time to come to your practice and copy medical records so the health plan can comply with Healthcare Effectiveness Data Information Set (HEDIS) requirements and create an accurate risk profile for the Centers for Medicare & Medicaid Services (CMS).

You schedule the appointment, but as you hang up, you wonder if this meeting is really necessary. Your practice generates detailed medical claims for this health plan every day, so couldn't they get the data they need from the claims?

This is a good question, and one with which many health plans and physician practices strugg...