BCBSIL Requests Patient Records

The Patient Protection and Affordable Care Act (PPACA) established state-based health insurance exchanges to sell insurance plans to any citizen, regardless of health status. The PPACA included risk mitigation provisions that apply to individual and small group market plans because of the possibility of increased numbers of riskier (i.e. sicker) health plan members. Under the risk adjustment program, HHS or the exchanges will assess the actuarial risk within each plan, based on the health status of its participants, and compare it to the average actuarial risk of all plans in the state, including the large group plans. Plans that have an enrolled population with lower than average actuarial risk will make payments to those plans that have enrolled individuals with higher than average actuarial risk.

According to BCBSIL (Blue Review September 2012), “Risk Adjustment makes it possible to understand the illness burden each provider is managing, enabling a fairer comparison of performance across health care providers. The use of severity-of-illness measures, such as diagnoses, to estimate the health risk (measurable or predictable health care cost expenditures) to which a patient is subject is a consistent, scientific approach to quantifying and measuring risk. It also allows comparison of quality outcomes and cost performance in the context of the specific patient health risks managed across health care organizations (hospitals, insurers) and communities.”