Chair: Viet Nguyen, Yan Heras
Scribe: Phung Matthews
Minutes Approved as Presented
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Meeting Minutes from Discussion
|Decision Link(if not child)|
|Management||Review ANSI Anti-Trust Policy|
Da Vinci FHIR Education and Implementation event
April 26th- April 30th
Data elements requirements for Risk Coding Report from Payer to Provider
Reviewed Last week discussion.
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.
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.
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.
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.
|Glossary Review - see Glossary|
Risk Adjustment Status...
Assume you are the payer sending or provider received the report on your risk for a patient, what are the statuses you would see?
Other statuses - pending
Is pending different from Null... Decided we didnt need Null becuase of when gaps are provided, there wouldbe up to data status info, not keeping tabs on history. Would only need null if you are tracking history.
What if provider says "code is not accurate" ? We keep wanting to limit the use case from payer to provider but in experience 10% of codes are inaccurate. why?
On the quality side, there is a need to pull people out of measures as well.
Invalidated status should be tracking on payer side, doesn't need to be tracked on the provider side - just have gap disappear.
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?
|Adjournment||Adjourned at PM ET|
|BCBS Alabama||Thomson Kuhn|
|Providence St. Joseph||Patty Craig|
- Re-evaluate the name of this use case as "Risk Adjustment" does not define the payment aspect of the primary focus. Need to discuss with CQI WG as well.
- Add to Phase 2 - Ability to remove and provide a reason for status change. e.g. the patient no longer has the condition.