New Process for HMO Open Access Claims-based Attribution Implemented

To ensure that Humana-covered patients are assigned to the physician they rely on most for healthcare, Humana now has a process that automatically moves patients currently enrolled in a Humana health maintenance organization (HMO) plan who are located in an open access market to an in-network primary care physician (PCP), based on their claims history.

Patients enrolled in an HMO plan in an open access market can visit any physician who is in-network, without a referral. This creates the potential for misalignments in attribution.

How this affects physicians

  • Each quarter, Humana will review up to 24 months of retrospective claims data to identify the physician the patient visits most often.
  • Once identified, Humana will attribute the patient to that physician.
  • Humana will update the member ID card and send a letter to the patient, notifying him/her of the change.

Physicians should note that patients with designated PCPs are not restricted from seeing other physicians for primary care. In the event that a Humana-covered patient disagrees with the PCP change made as a result of this process, he/she can call Humana customer service and change PCPs at any time.

Data used by Humana to attribute patients to PCPs:

  • Claims for evaluation/management (E/M) visits, wellness visits, physical assessments and some OB/GYN visits are reviewed
  • Visits within the last year take priority
  • Total visits, most recent visit date and total claim dollars are used in the event of a tie
  • Humana-covered patients must have three or more visits to cause a change in PCP

For more information, physicians can contact their provider engagement associate.