Commercial Risk Adjustment: One More Reporting Requirement

As part of Aetna’s commercial risk management initiative (see “Aetnas guide to commercial risk management [CRA]”), a medical records vendor will contact you twice this year on behalf of Aetna, in late August and early December, to request patient health assessment records for dates of service in 2017, Aetna told TMA reimbursement specialists.

The records requested by either of the vendors, Episource or ArroHealth, will be for patients enrolled in Aetna as individuals or part of a small group plan, either on or off the health insurance exchange. Reimbursement to you for your cost of providing the records is subject to your provider contract language.

Commercial risk adjustment is a method under the Affordable Care Act, with its mandate for insurers to cover anyone who can pay regardless of a preexisting condition, to level out the cost of insurance premiums for commercial plans. Essentially, the U.S. Department of Health and Human Services (HHS) collects funds from insurers who enroll more low-cost, healthy people and distributes them to insurers who enroll more high-cost people.

All payers, even Medicare, participate in the risk adjustment process, although the process for Medicare is slightly different from that of commercial plans (see the Aetna guide mentioned above for a comparison).

To this end, Aetna sends its members a brochure in their welcome packet that encourages them to complete an annual well-check, head-to-toe visit with their primary care physician or an Aetna vendor (MedXM or Your Home Advantage). Aetna pays for the annual well-check visits at 100 percent; labs and other testing are subject to deductibles and coinsurance — see Aetna’s Routine Preventive Visits policy (Aetna log-in required).

These health assessment visits, which result in a risk score for individual patients, are key to the risk adjustment program because the medical record should be complete and support both active and chronic conditions the physician is treating. Aetna has created a website, Aetna On Track, that you can use to manage Aetna patients’ health assessments

You can submit records electronically through athenahealth, Allscripts, eClinicalWorks, and NextGen. If you don’t use any of these electronic health record (EHR) companies, you can submit records by fax, mail, email, or temporary remote access to your systems, or with on-site assistance. In the event you are set up with Aetna to submit records through one of the above EHR vendors and you still receive a traditional medical records request, call Aetna at (855) 777-5425 for information.

For information on other payers:

Visit TMA’s Insurance resource page for news and information about commercial health plans.

Published July 27, 2017

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July 28, 2017