2021-04-01 Risk Adjustment Use Case Meeting

Review ANSI Anti-Trust Policy

• Da Vinci FHIR Education and Implementation event: April 26th- April 30th
• Kick Off recording and presentation are available

Register here. Early Bird Registration- April 5th, 2021

FHIR Risk Adjustment PSS 

• CQI WG approved the updated project title from FHIR Risk Based Coding to FHIR Risk Adjustment
• The Payer/Provider Information Exchange (PIE) WG reviewed the updated PSS and approved to become an interested party instead of co-sponsor
• Pending the Patient Care WG review for their co-sponsorship(scheduled on 4/12)
• Will start drafting FHIR IG proposal

Project scope update name from Risk Based Coding to Risk Adjustment

PIE- reviewed on Tuesday and thought they did not have the expertise on it so moved from Co-Sponsor to interested party. 

Next, Patient Care will review and determine if they will continue to be a Co-Sponsor.

Moving forward for the HL7 process. Will need to start an FHIR IG proposal as it is separate from the PSS proposal. 

Data elements requirements for Risk Coding Report from Payer to Provider

Glossary

Any changes in glossary terms? 

• change HCC Code to HCC category
• ICD code also is not specific enough- ICD9, ICD10, ICD11 and so forth
• Keep SNOMED as it is important to the exchange 
• Version is also important when reporting 
• Rx HCC driven by medical claims for Medicare but on commercial side, they have different models for it. 
  • medication data- can be used in the suspect conditions
  • in HHS there are some diagnoses from commercial models

Joint commission- need to have it so it supports all risk adjustments. 

RXC- model on commercial side and will use pharmacy data

RxHCC- model on medicare advantage side, will use medical data not pharmacy. Estimate of financial impact based on a medical condition

Focus on diagnosis on Medicare and help clarify that pharmacy data and procedure would be out of scope. 

Focus on medical risk adjustment model starting with Medicare but can be used for commercial models. 

Structurally there is no difference between HCC and RxHCC. Only difference is deciding which to send out to the providers. Same evidence can be used to close both gaps. If using both, can be redundant. 

Goal- to have provider document accurate diagnoses whether it is risk adjustment or not. 

Any data can be used to support the HCC category including DME. 

Do you always have supporting evidence when sending historic condition?

• may have a claim number or identifier (unique to endpoint that is being queried) or in the body of the response

On RA status- when stating confirmed for historic condition, is it because it is on this current year or from last year?

• may need to be agnostic for the model types 
• most recent date related to diagnosis on when it was confirmed
• do we want this to make it actionable to the providers? 
  • granularity on the model, should we consider pending?
• keep focus on date of service and date of record

Pick up next week on RA status