2021-04-08 Risk Adjustment Use Case Meeting

Da Vinci FHIR Education and Implementation event

April 26th- April 30th

Register here

Data elements requirements for Risk Coding Report from Payer to Provider

Glossary

Reviewed Last week discussion. 

• HCC Category:
  • Diagnosis - version of coding system is important for interpretation of the gap. 

Pick up - Risk Adjustment status

Shared additions to Data Elements Requirements - Clinical Data updates. https://confluence.hl7.org/pages/viewpage.action?pageId=108069858#DataElementsandAPIRequirements-ClinicalData 

Glossary - review.

Terminology Concern: 

Thinking from the Hospital Quality Improvement Perspective (not Payer) they call HCC, "Risk Factors."  In the concept of quality improvement, they assume all hospitals are the same throughout the US. They are risk adjusting patient factors.

This is more for the CMS risk adjustment payment.  Goal for CQI for risk adjustment, weather it's payment, quality improvement, or another use.  Risk adjustment on the quality side is very different than the risk adjustment on payment side. Name of the use case. 

Patty Craig - want to talk with CQI about use of the name "Risk Adjustment" if the focus is only for payment right now (HCC) and not including Quality. 

• Name the implementation guide vs. use case. 
• Quality vs. Payer -
• When calculating an observed rate, they risk adjust patient factors.... Patty can dust off a presentation
• Based on co-morbidity, age, etc. they think they are more or less likely to have been given the correct care.  Then P value created.   

What models are used?  It's based on the measure and data received. 

Risk adjustment is an extremely broad term.  Shouldn't be using it here without qualifying purpose.

• It wouldn't be practical to come up with a single use case to 

Risk Adjustment

• Health data EHR only  - not claims data - ECQM gets ICD-10 codes too though. 
• Patient related data
  • HCC - ICD-9 - based on claims data with cost factors back to the diagnosis.

Storming Ideas:

• "Claims-related Risk Adjustment"

• "Risk Adjustment to Set Payment Rates"

• "Risk Adjustment for Payments"

Getting this name right is of high importance of making it very clear and that this is member driven!

With a google of "Risk Adjustment" - first 2 pages are all payment related.

Agreed the name could cause confusion, so created action item to re-evaluate. 

Back office feature... more like an "In Process" that would change to confirmed or unconfirmed again.  

Not "Pending" but "In Process"  - 3:40pm ish was this discussion. 

Required to document to the highest level of specificity at all times.  Still want the diagnosis and the status of the HCC.

Action is not required unless the state is not confirmed. - may want to state this.  - Provider may want to take action if sitting in "in process" for a while, but that's secondary to what we are trying to do here. 

Next Step ' Phase 2 idea: Be able to report that they disagree to get it off the report. Will need to code the reason why.  Validation codes - e.g. provide says the diagnosis is wrong, the patient no longer has the condition. - very useful info to the payer to close the feedback loop. Payer to pull back into algorithms. 

HCC shows if diagnosis and condition is present, than that's that. 

Phase 1 - one direction provider to payer.  for now.  

Now we have 3 statuses, how do we capture the date?  

• The data of service is relevant.  
• project the visit for next week, 2months from now hearing more, but all relates back to date of service.
• You also need the date of message sent back - incentivised closure of HCCs, for financial reasons to get as many diagnosis to get submitted early in the year as possible - additional incentive to take action before the September sweets. 
• Active date the provider submits the record - submit claims in a timely way.  
• The next provider is looking at those dates, they have money on the line! 
• Are we sending the gaps to the PCP or to ALL Providers?
  • Answer: All providers!