Share medical records with Blue Cross, BCN to ensure access to care, improve patient experience

As a health care provider, you may find it frustrating when Blue Cross Blue Shield of Michigan or Blue Care Network request medical records, adding administrative tasks to your workload. We want you to understand why we request medical records and how they help us meet our shared goal: ensuring access to quality care while improving the patient experience.

Key reasons for medical record requests

There are many reasons Blue Cross or BCN may request a medical record.

• Claims validation and payment accuracy

  Blue Cross and BCN must ensure that services billed align with the care provided. Medical records are reviewed to confirm that claims meet medical necessity criteria, coding guidelines and contractual agreements. This process helps prevent fraud, waste and abuse, protecting resources for both members and health care providers.

• Quality assurance and risk adjustment

  Because Blue Cross and BCN participate in government programs, including Medicare Advantage and the Affordable Care Act exchanges, risk adjustment is crucial. Accurate coding and documentation of diagnoses are essential for calculating risk scores. These scores determine plan funding and help ensure that we can cover the needs of a diverse patient population.

• Appeals and utilization management

  When members or health care providers appeal a denied claim or request prior authorization for a service, we may need detailed medical records to assess the situation comprehensively. This ensures fair decisions based on clinical evidence.

• Regulatory compliance

  Blue Cross and BCN operate under stringent regulations, including audits by federal and state agencies. Requests for medical records are often tied to external audits, such as the Centers for Medicare & Medicaid Services Risk Adjustment Data Validation audits or Healthcare Effectiveness Data and Information Set, or HEDIS^®, reporting. These ensure plans meet quality and compliance standards.

Submitting medical records benefits providers

There are several benefits to health care providers for submitting medical records to Blue Cross and BCN, when requested.

• Faster claims processing and reimbursement

  When health care providers submit complete and accurate medical records upon request, it reduces delays in claims adjudication. Prompt submission can avoid claim denials or payment delays caused by insufficient documentation and can streamline the process for resolving disputes or appeals.

• Supporting quality metrics and incentive programs

  We use medical records to measure performance in quality programs, such as HEDIS or value-based care initiatives. By submitting medical records, health care providers can demonstrate their contributions to quality benchmarks, potentially earning higher incentive payments. In addition, providers with demonstrated high quality could be identified for their quality in provider directories, thereby attracting more patients.

• Reduction in future administrative work

  Submitting comprehensive, consistent and accurate documentation reduces the need for repeated requests for information. This minimizes the risk of future claim disputes, audits or rework, freeing up provider staff to focus on other priorities by reducing the administrative burden of responding to multiple rounds of inquiries.

• Facilitating risk adjustment and population health management

  For health care providers working with Medicare Advantage, Medicaid and commercial plans on the Health Insurance Marketplace, submitting complete records helps to ensure that risk scores accurately reflect patient complexity, leading to better reimbursement rates.

• Compliance with contractual obligations

  Many health care provider contracts include clauses requiring cooperation in submitting medical records. If providers use copy house vendors, the providers ultimately are responsible for providing the medical records.

Make sharing medical records easy with remote access to EMRs

Allowing Blue Cross and BCN to have remote access to the electronic medical record, or EMR, will help reduce the administrative burden on your office staff. This is a very secure, HIPAA-compliant resource that many provider offices use.

To discuss setting up remote EMR access, contact Ellen Kraft, R.N., director of Quality and Provider Education, at ekraft@bcbsm.com or 248-459-5175.

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA.