The Affordable Care Act and Commercial Risk Adjustment

Best practices you should follow

The Affordable Care Act (ACA) will create a new, permanent risk adjustment program for the individual and small group markets starting in 2014. Since health plans vary in their mix of healthy and sick enrollees, risk adjustment modifies premium payments to better reflect the projected costs of members served and compensate plans that enroll high-cost patients.

Over the coming months, Wellmark will introduce the provider component of the risk adjustment process. For now, we would like to remind providers of the importance of keeping patient records that help accurately capture the risk of each patient. This is especially important in regard to chronic conditions, ICD codes, and treatment details.


Why it's important.

Commercial risk adjustment will be used to estimate the relative risk of members enrolled in individual and small group ACA compliant plans. Insurers with lower risk populations will be required to make contributions to the risk adjustment program while those with higher risk populations will be reimbursed from the program. This is intended to create a level playing field for insurance carriers to price products by reducing incentives to attract healthier members. There may be situations in which Wellmark determines that medical records are necessary to support commercial risk adjustment in addition to existing initiatives that require submission of medical records. Wellmark, Inc. in conjunction with other national Blue Plans may request medical records for these situations.


Best practices you can adopt Providers are encouraged to adopt these best practices with medical record documentation which includes: i iChronic conditions should be reported every calendar year (e.g., leg amputation status must be reported each year). i iEach diagnosis should conform to the ICD-9 coding guidelines until transition to ICD-10 in October 2014. i iMedical records should be legible, signed, credentialed and dated by the physician. i iPatient's name and date of service should appear on all pages of the record. i iTreatment and reason for level of care should be clearly documented; chronic conditions that potentially impact the treatment choices considered need to be documented.




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