List Of People, Agencies, And Services That Access Your Medical Record | Jane Jackson, RN, CRC | RxEconsult

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Who Can Access Your Medical Record? Category: Healthcare Administration by - November 30, 2016 | Views: 21226 | Likes: 0 | Comment: 3  


Whoever pays for the medical insurance claim will access your medical record.  Medicare Advantage Plans, commercial insurance carriers, Medicare and Medicaid review your medical records ranging from justifying a claim, assessing quality measures, calculating risk adjustment payments, validating utilization of resources, overseeing case management of high-maintenance patients and pharmacy management. 

There are contracted vendors for many of these projects who will also request access to your medical records.


Medicare has many programs that review medical records for targeted information.  Information for these projects can be related to fees for billed services, coding inconsistencies, quality assessments, fraud or overuse.  A few of these are:

  • URAC (Utilization Review Accreditation Commission) is a non-profit organization that helps promote health care quality through the accreditation of organizations involved in medical care services.
  • CERT (Comprehensive Error Rate Testing) Contractors help calculate the Medicare Fee-For-Service (FFS) improper payment rate by reviewing claims to determine if they were paid properly
  • MAC (Medicare Administrative Contractors) Process claims and enroll providers and suppliers
  • MEDIC (Medicare Drug Integrity Contractors) Monitor fraud, waste, and abuse in the Medicare Parts C and D Programs
  • RAC (Recovery Audit Contractors) are designed to protect Medicare by identifying improper payments and referring potential fraud to the Centers for Medicare & Medicaid Services (CMS).
  • ZPIC (Zone Program Integrity Contractors) Investigate potential fraud, waste, and abuse for Medicare Parts A and B
  • HEAT (Health Care Fraud Prevention and Enforcement Action Team) established to build and strengthen existing programs combatting Medicare fraud while investing in new resources and technology to prevent fraud and abuse.
  • Medicare FFS Recovery Auditor - to identify and correct Medicare improper payments to Medicare beneficiaries and providers

Medicaid, just like Medicare, also reviews medical records for a multitude of reasons from claims, quality, and utilization.  Some of these programs are:

  • MFCU (Medicaid Fraud Control Units) investigates and prosecutes Medicaid provider fraud as well as patient abuse or neglect in health care facilities and board and care facilities.
  • MIC (Medicaid Integrity Contractors) to identify Medicaid overpayments and decrease the payment of inappropriate Medicaid claims.
  • OMIG (Office of Medicaid Inspector General) – audits to determine the nature and extent of services billed to the Medicaid Program and to verify that Medicaid policies and procedures are being followed.
  • PERM (Payment Error Rate Measurements) - annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the number of improper payments.
  • DOJ (Department of Justice) may investigate medical records for suspected criminal acts and omissions such as improper billing or referral arrangements.
  • OIG (Office of Inspector General) investigates tips and complaints from all sources on potential fraud, waste, and abuse. 
  • HHS (Health and Human Services) - Office for Civil Rights (OCR) conducts periodic audits of covered entities compliance with the HIPAA Privacy, Security, and Breach Notification Rules.
  • DADS (Department for Aging and Disabled Services) reviews medical records while conducting investigations.



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