Risk adjustment is a component of the Patient Protection and Affordable Care Act (PPACA) that is dependent on reporting accurate clinical information. According to PPACA, health plan carriers are required to provide diagnostic information to the Centers for Medicare & Medicaid Services (CMS) for all customers who enroll in their individual and family plan business through the Public Health Insurance Marketplace. The CMS then reviews the diagnostic information and determines the plan?s average risk. The average risk score is compared against that of other health plans participating in the same states and markets. If there are any health plan carriers
with a disproportionately higher risk score, CMS requires that those carriers with lesser risk compensate the ones with higher risk.
Importance of documentation
To ensure Cigna and CMS receive accurate information, you should always document and report treatment associated with the management of all medical conditions within the medical record. This will help ensure accurate diagnostic information is reported to the CMS. Code all conditions that exist at the time of
the visit. All active chronic conditions should be documented in your patient?s medical record as active at least once annually.
Medical records review
Reviewing medical chart documentation helps identify conditions that may have been evaluated and included in the patient?s progress notes, but were not included on the claim at the time of the visit. To help ensure we are meeting the new PPACA requirements, we have asked Altegra Health to assist us in conducting medical record reviews on an as-needed basis so we can report all diagnostic information to CMS as required.
Health care professionals contacted by Altegra Health will be asked to submit specific patient medical records to ensure the services and treatments provided were fully documented within the medical record. Details on how to submit the medical records will be provided by Altegra Health.
Thank you in advance for helping us provide CMS with accurate information.