Products & Programs PharmacyMedicare AdvantageMarch 1, 2024

Overview of Medicare risk adjustment in-office prospective programs

Anthem’s in-office prospective programs are designed to encourage the comprehensive annual assessment of patients’ health and support the complete and accurate documentation and coding of active, present conditions assessed. Collecting accurate and complete diagnosis information helps to support proper treatment, care management, and patient care. Providers participating in these programs may have the opportunity to receive reimbursement for the additional administrative time associated with their participation.

Key takeaways:

  • Enhanced provider-patient engagement through comprehensive annual assessments and individual care planning
  • Streamlined workflows designed to reduce administrative time spent by a provider at the point of care, allowing the provider to focus their time on their patients 
  • Patient-specific insights to support a comprehensive assessment and improvement in the accuracy and completeness of diagnosis data collected 
In-office prospective programs

In-office assessment program

Point of care technology

In-office patient assessment program that uses a form to message potential conditions,1 recommended screenings, and other health information to the providers; this program is designed to support complete and comprehensive annual exams and promote earlier detection of chronic conditions

Technology solution designed to streamline the Medicare Annual Wellness Visit (AWV) and other preventive services to improve provider workflow efficiency, support the continued delivery of quality care, and improve the accuracy and completeness of diagnosis data collected during a face-to-face encounter

Additional information about the in-office prospective program based on last year’s data:

  • Patients who did not receive an in-office prospective program had, on average, an MLR increase of 2% YoY.
  • Patients who received a comprehensive in-office assessment via the in-office prospective programs had, on average, 0.3 HCCs2 reported based on that encounter.
  • Providers who actively participated in the in-office prospective programs received, on average, 2%–5% increase to their Persistent Condition Validation (PCV).

We are committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.

1 Potential conditions include previously reported conditions and/or conditions suspected based on clinical and/or statistical indicators. Potential conditions should be assessed by the provider during a face-to-face encounter with a patient; only those conditions the provider determines, based on their assessment of the patient for the condition(s) and independent clinical judgment, to be active and present should be documented, coded, and reported.
2 Hierarchical Condition Categories (HCCs) are groupings of clinically related diagnoses with similar medical costs; each HCC is assigned a risk factor value by CMS. Only ICD-10-CM codes that map the CMS-HCC risk adjustment model are used in risk score calculation.

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-051061-24-CPN50903

PUBLICATIONS: March 2024 Provider Newsletter