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 LifeWise 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.

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, LifeWise requests medical records from providers in order to validate that claims information match documentation. You may receive a letter from Altegra Health requesting copies of some of your patients' records.

You may also receive a letter from Cognisight to participate in the annual Risk Adjustment Data Validation (RADV) Audit mandated by CMS every summer. For RADV, a letter will come from Cognisight requesting copies of some of your patients' records.

• Learn more about medical records requests

Coding and documentation best practices

The Affordable Care Act mandates risk adjustment. This means that all members’ chronic and complex conditions need to be revaluated in a face-to-face visit, documented in the medical record, and coded annually. Accurate and timely documentation and coding helps our members by:

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

Visit our Quality & Coding Tools page for quality measure tip sheets, documentation and coding guides, web-based training, and more.

If you have questions email us or call 877-342-5258, option 4.