In July, Anthem Blue Cross will begin chart reviews on enrollees who purchased Affordable Care Act (ACA)-compliant plans in either the individual and small group insurance markets (both on and off the exchange, known as “Covered California”).

The records 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)].

During the risk adjustment audit, Anthem will review diagnosis code data obtained from the medical records of ACA-compliant individual and small group patients. This is not a typical audit on the physician practice; rather, Anthem 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 determine a risk score, which is a measure of how costly an individual is anticipated to be, and will be reported to the Centers for Medicare and Medicaid Services. If at the end of the annual risk adjustment assessment, Plan A has a lower risk average score than Plan B, then Plan A has to issue a payment to Plan B. In a nutshell, the program is intended to prevent payors from cherry picking only healthy enrollees.

Anthem reports it will also utilize the data to better manage patient health conditions.

Anthem has contracted with Inovalon, Inc., a secure clinical documentation service, to conduct the medical chart reviews. Inovalon will utilize 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 the provider’s electronic health record (EHR) system (only upon authorization from the practice)

In cases where fewer than six medical records are being requested for review, Inovalon will contact each provider’s office and request the information via fax or mailing of medical chart information.

In cases where Inovalon is requesting more than six medical records to review, the company will contact the provider’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’s EHR system.

Questions about the letter or the enclosures can be directed to Inovolan at (877) 448-8125. Anthem has also published an FAQ about the commercial risk adjustment records request. Questions about the initiative can be directed to Inovolan at (800) 390-3180 or CRA@anthem.com.

For more information on commercial risk adjustment, visit the California Medical Association website at www.cmadocs.org.