MCOs do audits primarily to make sure that clinicians are actually performing the services for which they are billing. In addition, several providers stated that MCOs may need to review records in order to comply with accreditation requirements such as those developed by the National Committee for Quality Assurance (NCQA).
An MCO might also request a medical record because of quality-of-care concerns, whether expressed by patients, other providers, or other sources. One MCO in our study also reviews the full record when a patient chooses to go to an out-of-network hospital. All of the providers we spoke with stated that the MCOs include in their provider contracts the right to access the full medical record at any time. MCOs may audit the provider’s chart system on site or they may simply ask the clinician to send in a sample of charts.
MCO requests for complete charts can be problematic because, in practice, many therapists do not separate psychotherapy notes from the general medical record. These notes reflect the therapist’s thoughts and opinions during treatment and may also contain information on patients’ family members who probably had not agreed to have their information disclosed to the therapist, let alone the MCO. Once the information is in the chart, anyone at an MCO that handles the chart, including data clerks, could have access to that information. Releasing sensitive information in charts can have serious consequences because an MCO clerk could be required to testify in court as to what he or she saw in a chart. To illustrate the severity of this possibility, one provider used an example of a patient who was a physician being treated for substance abuse. The physician had been writing fraudulent prescriptions and consuming the drugs himself. If this is recorded in a file and an MCO clerk later sees it and reports it, the physician could lose his medical license and face criminal charges.
Several providers mentioned that they do not keep separate charting systems for physical and mental health care because of the administrative hassles. Two providers said explicitly that they do not separate their notes even though they know they should because they have never been audited. If they were to be audited, they would pull out the notes before the MCO came on site.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)