2021-03-25 Risk Adjustment Use Case Meeting

Da Vinci FHIR Education and Implementation event

April 26th- April 30th

Register here

Early Bird Registration- April 5th, 2021

Introduction of Case leads 

Use Case Overview and Scope

• Risk adjustment is compensation methodology that funds government managed care insurers. 
• documentation of all risk-adjustments conditions must be captured every year- this become important for the standardization
• Goal- having standards for payers to communicate risk-based coding gaps to providers. 

Patient scenario example

HCC- Hierarchical Condition Category

• What does this use case address?
  • Patient may have one or more chronic condition to address. Communication is important to ensure patient receive comprehensive care
  • Provider-addressing conditions will results in more accurate risk-based payments to payer. 
  • make sure information is flowing for appropriate care for accurate diagnosis. 
  • Use case looking at payer to provider

Certified risk coders- certification available for individuals working on risk adjustments

Workflow- will need a trigger to start the process. May be from provider or payer side

Data Requirements- States on HCC codes- being worked on 

HCC Code labels- break out for the categories. 

• permanent, persistent, Acute, Chronic

CMS has standardized condition categories but would have Da Vinci to either use these as a standard for codeable concept

Anna Taylor 

Does this use case address information going from provider to payer?

Murtha, Brian 

We believe that existing conduits for data flow should be sufficient to capture diagnoses that are adequately documented by the provider. This is not to say improvements in supplemental data collection can't be made, but we are focusing on improving the payer>provider flow, for which no standard conduit exists.

Anna Taylor 

This will put pressure on providers to advocate for extending periods for recapture. @viet — as long as we are thinking of it as phase 2.

Brent Zenobia 

There is risk-adjustment information that needs to make its way back from the provider to the payer that can't flow thru normal mechanisms. Since risk adjustment gaps are suspected based on analytics or persisting from prior years, there needs to be a mechanism for the provider to communicate when the suspected gap is invalid. There is no existing mechanism I'm aware of for providers to communicate HCC invalidations to payers.

Susan Bellile 

In the communication from payer to provider, is the intent to include all conditions that the member is known to have or is suspected to have - or only the "gaps" (those conditions that have not been documented in the current year)?

Viet Nguyen, MD (Da Vinci PMO) 

@Brent and @Susan - these are the kinds of questions and issues that need to be addressed in the phase of the Use Case development on our way to an IG.

*this next phase

Karl Everitt 

@Viet - I believe @Brent's point about invalidations is an important one. Giving MDs the ability to shut off alerts for wrong triggering diagnoses is a key satisfier for the MD. Without that input from the MD, alert fatigue kicks in, and the MDs can start to ignore both this noise AND the valuable data. Sounds like "provider to payer" communication is Phase 2.

Brent Zenobia 

@Karl @Viet To add to the point, just because there was a dx in a prior year doesn't mean it was correctly diagnosed. Rheumatoid arthritis is a classic example. So there are different kinds of invalidations: whether the condition was never correctly diagnosed; whether there is no current evidence of the condition; and whether the suspected condition is at the wrong severity level (e.g. HCC 18 instead of HCC 19.) So There is a provider consultation aspect

Anna Taylor

How will this work with ATR

Karl Everitt to Everyone

@Brent - exactly. What Brian was just going over is relevant - "gap closed" and <when closed> will allow the report consumer to prompt (and re-prompt) at an appropriate frequency.

Viet Nguyen, MD (Da Vinci PMO) to Everyone

@Brent - that's a good point. For some of these questions, we have to assess how frequently it happens so we can determine if it fits into the IG or is an out-of-band process.

Viet Nguyen, MD (Da Vinci PMO) to Everyone

@Anna - if Gaps in Care is any indication, we can use the ATR group list and do a population level Coding Gaps report.

Linda Michaelsen to Everyone

@Brent - is there any methodology to let the payer know that a potential coding gap is not one?

Floyd Eisenberg 

Is there some way to incorporate some validation of accuracy of condition/diagnosis? E.g., seek an algorithm to evaluate diagnosis, specific observations (results) and clinical course to determine the accuracy and precision of the condition to evaluate for risk?  I realize that is a more granular level of data but it may be helpful.

Murtha, Brian 

@Carl and @Brent - Agree with needing to get the provider responses back. My earlier comment was to say that a provider simply saying "yes" is not sufficient to capture enough data to submit--we need the entire encounter. That's not to say we can't capture responses, just that this feature won't replace the need for traditional documentation.

Brent Zenobia

@Viet - depending on the HCC, the invalidation rate varies based on a number of variables - the quality of the suspecting, the clinical characteristics of the disease, etc. etc. For example, you might see an overall invalid HCC gap rate of 10% or so, but for certain HCCs it will be much much higher - say, as many as 30-40% invalids. This is particularly true in situations where an acute condition may or may not become chronic, like DVT or PEs.

Floyd Eisenberg 

Also consider the difference between diagnosis first documentation and date of onset - USCDI is currently considering adding the differentiation and current documentation is somewhat ambigious. But date of onset may have more significance to risk than date the condition is recognized.

Murtha, Brian 

@Susan - I want others to weigh in, but so far we've talked about sending everything, then allowing the recipient to filter out non-actionable statuses, as appropriate.

Brent Zenobia 

@Linda - I've done some work to develop a mutually exclusive and collective exhaustive way of coding provider invalidations, if that's what you were asking?

Anna Taylor to Everyone

Excellent. Thinking about DPC — and how we can pull by individual and group.

Viet Nguyen, MD (Da Vinci PMO) 

@Brent - We'll need to unpack this challenge and determine if the problem you describe is a problem of  primary data documentation, data quality, data availability, or some other aspect that is specific to the category HCCs. We can address some aspects with improving interoperability of data. some aspects may need other interventions like educating providers.

Susan Bellile 

@Brian - seems logical to include "everything" in the communication from the Payer to the Provider.  It would just need to be easy to distinguish "this is a condition the member has and it has already been documented on a claim this year, so we're not asking you [provider] to take any action" vs "we need you [provider] to assess this potential or not-yet-validated condition".

Murtha, Brian 

@Susan - Exactly.