May 09, 2017
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement Practice Management
QUESTION: My office is receiving an increased number of medical record requests from various payors. Can I bill the payor for copying medical records requested by the plan?
ANSWER: It depends. There are several different types of requests for records including, but not limited to, a contested claim, commercial risk adjustment audit, Medicare risk adjustment audit, or special investigations audit.
Most managed care contracts include language that require practices to generally comply with medical records requests at no additional cost. However, if neither the contract, nor payor policies or procedures require you to bear the cost of those copies, there is no law to prevent you from billing the payor for reasonable copying expenses.
If the request for records is voluminous, which can sometimes be the case with commercial risk adjustment records requests, practices may wish to contact the payor and request that it send a copy/scanner service out to the practice or request that it reduce the volume of records being requested.
For most PPOs, except the Blue Cross Prudent Buyer and Blue Shield of California PPOs, if the physician is not contracted or the contract is silent on charging for copying costs, the insurer is required to pay providers for copies related to a contested claim and for patient records (Insurance Code §10123.131). In these instances, the insurer must pay the provider at the same rates established by the patient access laws, which are twenty-five cents ($.25) per page, or fifty cents ($.50) per page for records that are copied from microfilm and all reasonable costs, not exceeding actual costs, incurred by the provider to provide copies of x-rays, or tracings derived from electrocardiography, electroencephalography, or electromyography.
In general, however, payors are prohibited from requesting more information than is reasonably necessary to determine whether the services are covered and medically necessary, and to determine payor liability.
For more information, see CMA On Call Documents #4202, "Health Plan Access to Medical Records," and #4002, "Medical Records: Allowable Copying Charges." These documents are available free to CMA members. Nonmembers can purchase On-Call Documents for $2 per page.