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Anthem Blue Cross begins medical chart reviews for exchange patients



August 05, 2014
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement Practice Management 

<p>In July, Anthem Blue Cross began chart reviews on enrollees who purchased an individual exchange or mirror product. Similar to the Medicare Risk Adjustment Audit process, and as required by the Affordable Care Act (ACA), the audit is designed to identify the health status and demographic characteristics of exchange/mirror product enrollees.</p>
<p>Blue Cross will review diagnosis code data obtained from the medical records of exchange patients. 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 or patients who are predicted to be healthier. This information will be utilized to report to the Centers for Medicare and Medicaid Services the health status of exchange plan enrollees. Blue Cross reports it will also utilize the data to better manage patient health conditions.</p>
<p>Blue Cross has contracted with Inovalon, Inc., a secure clinical documentation service, to conduct the medical chart reviews for exchange/mirror product enrollees. Blue Cross previously utilized Inovalon for its Medicare Advantage risk adjustment audits and the recently requested patient health assessments.</p>
<p>Inovalon will utilize several methods of collecting medical record information from physician practices, including:</p>
<ul>
<li>Scanned or faxed medical records that providers&rsquo; offices send to Inovalon</li>
<li>Onsite medical record reviews by clinical personnel</li>
<li>Automated medical record retrieval from the provider&rsquo;s electronic health record (EHR) system </li>
</ul>
<p>In cases where fewer than six medical records are being requested for review, Inovalon will contact each provider&rsquo;s office and request the information via fax or mailing of medical chart information.</p>
<p>In cases where Inovalon is requesting more than six medical records to review, the company will contact the provider&rsquo;s office and arrange a time convenient to visit the office to collect the appropriate information or to discuss accessibility of the information from the provider&rsquo;s EHR system.</p>
<p>Questions about the letter or the enclosures can be directed to Inovolan at (877) 448-8125 between 8 a.m. and 11 p.m., EST. Questions about the initiative can be directed to Anthem Provider Services at (855) 854-1438.</p>

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