Anthem Blue Cross continuing medical record reviews and patient health assessments through Inovalon

December 14, 2016
Area(s) of Interest: Electronic Health Records Health Information Technology Practice Management 

In the Anthem Blue Cross December Professional Network Update, the insurer published a reminder about how it is working with Inovalon, a secure clinical documentation service, to meet the patient reporting requirements specified under provisions of the Affordable Care Act (ACA). 

Physicians continue to report receiving requests for medical records from Anthem related to “risk adjustment.” These record requests are a result of the commercial risk adjustment program created by ACA Section 1343. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to meet the needs of a diverse population. Because the information reported by physicians and other providers is at the heart of payment adjustments, health plans must engage providers by requesting copies of medical records that accurately reflect diagnoses and/or underlying health conditions to comply with risk adjustment program requirements [77 Fed. Reg. 17220, 17241 (March 23, 2012)].

Anthem has contracted with Inovalon to conduct medical chart reviews, utilizing one of several methods of collecting medical record information from physician practices, including:

  • Scanned or faxed medical records that providers’ offices send to Inovalon

  • Onsite medical record reviews by clinical personnel

  • Automated medical record retrieval from providers’ electronic health record system (upon authorization from the practice)

Anthem has also announced that it will continue to offer financial incentives to physicians for completing member health assessments for patients with certain exchange/mirror products. The health assessments are voluntary and are separate from anything related to the commercial risk adjustment requests.

Anthem will continue to work with Inovalon throughout the year to request that physicians complete the health assessments. The assessments will be completed using Inovalon’s secure, electronic tool (ePASS) or using the Encounter Subjective, Objective, Assessment and Plan (SOAP) Note provided by Inovalon for each identified patient.

For patient assessments completed for dates of service on or after June 1, 2015, physicians are now eligible to receive $100 for each properly submitted electronic SOAP note submitted through ePASS, in addition to their normal office visit fee. Physicians electing to submit their patient assessment data to Inovolan via secured fax, instead of electronically, are eligible to receive $50 in addition to the office visit fee.

The information is being requested as part of a Covered California requirement that participating health plans collect and maintain information about the health status of their plan enrollees to better manage their health conditions.

According to Anthem, there are no penalties for non-compliance with the health assessment at this time.

Physicians who have questions regarding the health assessment program can reference the Anthem FAQ or can contact Anthem Provider Services at (855) 854-1438. For specific health assessment questions, contact Inovalon at (877) 448-8125.


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