Risk Adjustment may be the biggest challenge ahead for health plans

Timely new service delivers much needed support

BRAINTREE, MA.  – This fall, health plans will face a major influx of new enrollees that must be issued coverage under the Affordable Care Act (ACA), but these plans have limited means to effectively evaluate the enrollees’ health. This will leave health plans scrambling for ways to minimize potential losses or maximize potential gains under the Risk Adjustment provision of the ACA.

To meet this challenge, MIB Group, an industry leader with more than a century of expertise in insurance risk identification, has developed HealthRisk ID, a one-of-a-kind service that offers insurers an early, cost-effective way to get relevant and accurate health information on their new enrollees. HealthRisk ID uses North America’s largest database of medical conditions on insurance applicants to provide insurers with accurate and specific medical information, so they can proactively identify members with qualifying medical conditions for risk adjustment, disease management and wellness initiatives.

“Identifying and qualifying enrollee health risk upfront may mean the difference between receiving a check and writing a check,” said Doug Mertz, MIB vice president. “With millions of dollars potentially at stake in risk adjustment transfers, we believe insurers using HealthRisk ID will have a distinct advantage in the market.”

Identifying high risk enrollees

“Health plans face a great deal of uncertainty in planning for the 2013 open enrollment period.  HealthRisk ID gives health plans the confidence that the enrollees with high-risk conditions can be promptly identified, and a plan’s limited resources for conducting health risk assessments can focus on top-priority enrollees at the earliest possible time. This ensures that those enrollees are included in the time-sensitive risk adjustment workflows and calculations,” continues Mertz.

In fact, industry experts predict risk adjustment will fundamentally change the economics of health plans such that members with risk-adjusted conditions will play a critical role in driving profits.

Identifying and qualifying enrollee health risk upfront may mean the difference between receiving a check and writing a check

HealthRisk ID information is furnished to MIB by insurance underwriters on individuals who have applied for life, disability income, long-term care and critical illness insurance to MIB’s 450 U.S. and Canadian member companies. Underwriters obtain reliable information from attending physician statements, laboratory testing, qualified physical exams and applicant interviews and admissions. As a business associate of health plans, MIB safeguards this information in compliance with HIPAA.

HealthRisk ID medical conditions are mapped to both HHS/CMS-HHC and ICD-9 qualifying diagnostic codes for risk adjustment so they can be used by health plans offering individual and small group coverage and Medicare Advantage plans.
HealthRisk ID lets insurers quickly segment enrollees along a spectrum of risks:

  • High-risk enrollees with qualified medical conditions that may be eligible for inclusion in an insurer’s HHS-approved risk adjustment calculation and for disease management and wellness programs.
  • Least-risk enrollees who were previously underwritten and had no significant medical conditions reported.
  • Unknown risks enrollees who have no information reported, making them possible candidates for follow up assessments.

HealthRisk ID will be available starting Oct. 1, 2013, when open enrollment is slated to begin under healthcare reform. Insurers can learn more about how the HealthRisk ID service can benefit them by visiting www.mibgroup.com/hrid.

About MIB and HealthRisk ID
MIB is the life and health insurance industry’s most trusted resource for risk assessment information and analytical services. Owned by the industry it has served for more than a century, MIB is uniquely positioned to aggregate industry insights in order to develop products and services for its members that improve their risk management decisions www.mibgroup.com
MIB HealthRisk ID is provided exclusively to members of the MIB Group, Inc. for purposes that are legally permissible under the Affordable Care Act and will not be used to determine eligibility for insurance. HealthRisk ID is a service of MIB Solutions, Inc., a wholly-owned subsidiary of the MIB Group, Inc.