July 26, 2011



I received a request for 28 patient records from an insurance company that I was already reimbursed by for the requested services. Should I send them in?

Thanks, Dr. R


Whether you should send the records in absolutely depends on your specific circumstances and you should work with a healthcare attorney to devise a strategy when responding to any such request. That being said I will provide some general comments - Insurance companies are entitled under NYS law to review claims already paid for a period of 2 years after payment (6 years if there is an allegation of fraud). However, the insurer is required to adhere to other relevant statutes when requesting additional documentation for review. This is relevant because NYS has privacy laws that are more prohibitive than HIPAA. So, while the letter request you have received may cite HIPAA and state that the insurer is entitled under HIPAA to receive additional records, the insurer may, in fact, not be entitled to receive additional documentation under the more protective NYS laws. Under the relevant provisions in the Public Health Law, a contemporaneous release for records is required, and any request must be narrow and specifically tailored. Therefore, a general request for records on 28 patients may not adhere to the NYS requirements, and you may be in violation by sending the records in. Patient privacy is one of the many areas you need to take into account when responding to a request.

Here, it sounds as though you have been selected by the insurer for a "post-payment" audit. (Be advised that in almost all cases of a post-payment review, I have seen the practitioner receive a "recoupment demand" for money to be returned to the insurer post-audit.) In order to better position yourself should a recoupment demand be headed your way, be sure that you do not wait until after you have sent the records in to contact competent counsel - failing to do so may put you at a significant disadvantage.


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