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Under the Patient Protection and Affordable Care Act,
also known as Health Care Reform, the process of risk
adjustment is being expanded to include commercial
members in an individual or small group plan offered
both on and off the Health Insurance Marketplace. This
process currently exists for our Medicare Advantage
HMO and PPO plans.
Under Health Care Reform, everyone has access to
health insurance regardless of their health status.
In order to try to create a system in which payers
and their provider network are compensated for the
risk associated with the members they treat (i.e.,
risk-adjusted payments), complete and accurate
information of each individual's health status through
claims and encounter data is critical.
Risk adjustment
This risk adjustment process uses demographics
and illness burden (measured by diagnosis code
information), to assign members' risk scores. It also
requires proper documentation of conditions for each
member/provider encounter to accurately assess risk
scores. The overall objective is to stabilize risk and
prevent adverse selection by insurers.
However, there are some key differences between
the risk adjustment models used for commercial and
Medicare Advantage members. The commercial
model is designed to redistribute money from insurers
with healthier patient populations to those that have
a sicker patient population, and either the state or
federal government is responsible for operating the
commercial model. The Medicare model is set up
to determine the payment to Medicare Advantage
organizations and is operated by the federal
government.
How does this impact my practice?
In risk adjustment, there is an increased dependence
on accurate coding practices. By having precise
coding, it will provide better insight on the true risk
associated with members and allows for a more
accurate projection of medical cost, enabling practices
to obtain greater financial stability. It also allows
practices to analyze and evaluate the effectiveness of
care management programs, reduce practice variation,
and help drive better quality outcomes for members.
Practices can use these steps to make sure they
achieve the best results:
- standardize the medical documentation and coding
process consistent with billing procedures;
- adopt electronic health records and other
technologies that support greater coding accuracy
and efficiencies;
- engage office staff and coders to ensure the best
coding practices are being used.
Support from IBC
IBC contracts with Inovalon, Inc., an independent
company, to provide support services for risk
adjustment. These services ensure that members with
targeted diagnosis gaps are identified for follow-up
care and that practices have access to the necessary
tools to accurately capture and report diagnostic code
information. Through Inovalon, the following programs
are designed to help your practice attain the best
results:
- Personal Health Visits. Identified members are
offered supplemental care management services
such as Personal Health Visits at their home or other
location where IBC has contracted for these services
(i.e., Walgreens).
- ePASS®. Providers can use the
ePASS® system to
ensure that diagnosis gaps for Medicare Advantage
HMO and PPO members and certain commercial
members are being reported back to IBC. Providers
who submit information to ensure quality and
consistent coding through ePASS® for Medicare
Advantage HMO and PPO members and certain
commercial members are eligible to receive a
financial incentive.
- Medical record review. An Inovalon representative
will contact certain providers to determine the most
appropriate method of retrieving medical charts for
select members from your practice. Certified coders
or nurse practitioners will either come on-site to
providers' offices to retrieve the charts or providers
may be asked to fax the charts to Inovalon. Providers
will receive compensation for each medical chart
retrieved. Integration with select electronic medical
record systems is also available to provide greater
efficiencies and to minimize provider disruption when
obtaining necessary medical records.
If you have any questions regarding risk adjustment,
please contact Customer Service at 1-800-ASK-BLUE.