Commercial Risk Adjustment

  • The Provider’s Role in Commercial Risk Adjustment

    Commercial risk adjustment is part of the Affordable Care Act. Its goal is to stabilize risk for individual and small group plans inside and outside of the Exchange marketplace. It helps health plans like Premera continue to offer much-needed coverage for a diverse population.

    Providers play a huge part in the overall success of commercial risk adjustment. From specifically coding patient visits to submitting claims and assisting with audits, risk adjustment involves all levels of staff in a provider’s office.

    Here you can learn more about how we’re partnering with providers in commercial risk adjustment efforts through medical records requests, our Enrollee Health Assessment Program, and provider education.

    Medical Records Requests

    Medical records requests are a key part of risk adjustment activities and are necessary to help us manage risk and make sure our members have access to quality, affordable healthcare. Each fall, in compliance with requirements of the Affordable Care Act, Premera requests medical records from providers in order to validate that claims information matches documentation. You may receive a letter from Altegra requesting copies of some of your patients’ records. And beginning in 2016, providers may be asked to participate in an annual Initial Validation Audit mandated by CMS.

    Coding and Documentation Best Practices

    With the Affordable Care Act’s risk adjustment mandate and the recent transition to ICD-10, there is increased focus on documentation and coding standards. Accurate and timely documentation and coding allows for more meaningful data exchanges between carriers and providers. This helps our members by:

    • Identifying new problems early
    • Reinforcing self-care and prevention strategies
    • Coordinating care collaboratively
    • Avoiding potential drug/disease interactions

    The following resources can help you improve documentation and coding:

    Enrollee Health Assessment Program

    Premera's Enrollee Health Assessment (EHA) Program supports members with chronic conditions by encouraging them to do proactive things like select a primary care provider (PCP) and participate in a care management program. PCPs participate by completing Annual Health Review visits for identified members and receive an enhanced visit reimbursement for doing so. To participate, you’ll need to sign a contract. For more information, call Physician and Provider Relations at 877-342-5258, option 4, or learn more about EHA through the links below.

    EHA Program

    Patient Communications

    Annual Health Review Visit Documentation and Coding

    For More Information

    If you have questions, please call Physician and Provider Relations at 800-722-4714, option 4, or email ProviderEngagementTeam@premera.com.