Risk Adjustment

Risk Adjustment seeks to level the playing field by discouraging adverse selection of members through a two-step process: Risk Assessment, which evaluates the health risk status of an individual to create a clinical profile; and Risk Adjustment, which estimates the resource utilization needed to provide medical care to an individual.

If you have specific questions about Risk Adjustment, Risk Adjustment Validation Audits, medical record retrieval or other related topics, please email us.

Your Role in Risk Adjustment

The success of Risk Adjustment is largely dependent on the daily administrative best practices observed by you and your staff. Is your clinical documentation accurate, clear and complete? Do the claims you submit accurately reflect the care that was provided to each patient? Are you prepared to respond promptly to requests for medical records, as required for Risk Adjustment auditing purposes? This section of our website includes information and resources to help you and your staff understand how Risk Adjustment may affect your office and what you can do to prepare, in the event of an audit.

Accurate Medical Records

Providers play a critical role in helping ensure the integrity of the data used in calculating overall health risk by providing:

  • Medical record documentation sufficient to support ICD-10-CM coding to the highest level of specificity for claim/encounter data submission and risk trends
  • Adherence to ICD-10-CM industry and reporting coding guidelines for conditions that are monitored, evaluated, assessed or treated (MEAT)
  • A comprehensive health status for each patient
  • Accurate, ICD-10-CM coding for every patient, every time

Reinsurance and Risk Corridors

Reinsurance and Risk Corridors are two temporary programs also established by ACA.

  • Reinsurance is a transitional program established in each state to help stabilize premiums for individuals with higher cost needs who obtain insurance coverage during the first three years (2014 through 2016) of individual marketplace operation.
  • Risk Corridors are designed to protect against the uncertainty in rate setting during the first three years of the Marketplaces by creating a mechanism for sharing risk between the federal government and qualified health plan payers.

Medical Records Requests

Throughout the year, Blue Cross and Blue Shield of Illinois (BCBSIL) may request medical records from independently contracted providers, in compliance with Affordable Care Act requirements. Medical record audits are necessary to validate that clinical documentation supports information submitted on the associated claims. Health plans are required to conduct independent audits to validate the information submitted to the government for risk adjustment purposes.

You may receive a letter from a contracted vendor requesting copies of medical records for some of your patients. BCBSIL contracts with vendors to request and collect medical records.

Provision of Medical Records without a Signed Authorization from a Member

Contracted providers are obligated to abide by Section 164.506(c)(4) of the HIPAA Privacy Rule, which permits medical providers to disclose patient medical information without a signed authorization from the member if requested by the health plan or its authorized representative for purposes related to treatment, payment or operations.

Helpful Industry Links

Read more about the new Risk Adjustment, Reinsurance and Risk Corridors standards in the Federal Register.

Regulatory Overview/HHS Risk Adjustment Model

Clinical Documentation/Coding