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Anthem Blue Cross annual Medicare Advantage chart review under way

May 29, 2014
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Practice Management 

In the May 2014 issue of the Anthem Blue Cross Professional Network Update, the insurer announced that its annual Medicare risk adjustment scoring audits are now under way. Risk adjustment is how Medicare analyzes and adjusts the capitation amounts paid to Medicare Advantage health plans.


The risk adjustment audit is required annually by the Centers for Medicare and Medicaid Services (CMS) and is designed to identify the health status and demographic characteristics of Medicare Advantage enrollees. This is not a typical audit on the physician practice; rather, Blue Cross is looking to identify conditions/illnesses that demonstrate patients who are at risk for being sicker, which can result in higher capitation payments to Blue Cross from CMS, or patients who are predicted to be healthier, which can net lower capitation payments.


The Blue Cross Prudent Buyer agreement requires physicians who receive an audit notice to comply with the request (see exhibit F, section 7.1 to the Medicare Advantage PPO Participating Physician Agreement) within 14 days. Blue Cross has hired Verisk Health, formerly known as MediConnect Global, Inc., to assist with the medical chart review program.


The physician notices typically include a request for certain Blue Cross Medicare Advantage patient records within the range of the 2013 calendar year to the present. Practices can, however, contact Blue Cross and request that they provide the specific dates of service in question. Additionally, the risk adjustment audits usually involve only a handful of patients per practice, but if the request is voluminous, practices may wish to contact Blue Cross and request that it send a copy service out to the practice.


Additional information on risk adjustment audits can be found on the Blue Cross website. (Log in as a provider, click on "Medicare Advantage Plans & Benefits," and search "risk adjustment 101.") Physicians can also contact Blue Cross directly at (877) 489-8437.

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