InsuranceHealth Ins Carriers & MCO's
Many members have reported receiving a letter, phone call or both from Inovalon on behalf of Horizon. Inovalon is a company that has performed what are called Risk Adjustment Reviews for various carriers over the years. There are several companies that have done these reviews for insurance carriers including Ciox, ArroHealth, Episource and others. Horizon has confirmed that these requests are for Risk Adjustment Reviews.
Risk Adjustment Reviews essentially are gathering of information on a carrier’s patient population health to report to the government, which can affect reimbursement levels of government sponsored programs such as Medicare Advantage and Medicaid managed care. The carriers are required by law to perform these reviews.
Since these reviews have been required by law following the enactment of PPACA (Obamacare), we have not seen any negative outcome for a provider stemming from a Risk adjustment Review. Also, if you are in-network you are obligated per your contract to comply with the records request.
We have heard that many of these letters insist that you respond with the records within seven days. These companies often write very short time frames to create a sense of urgency to make sure the letter isn’t put aside and lost in the shuffle. I believe the most recent Horizon participating provider agreement allows 20 days to comply with records requests, so you should have at least that long. If you contact them and provide the records in a reasonable amount of time (under the 20 days) this will likely not be an issue.
If we become aware of any other function or outcome of these records requests we will advise membership immediately.