2021-04-15 Risk Adjustment Use Case Meeting

Da Vinci FHIR Education and Implementation event

April 26th- April 30th

Register here

FHIR Risk Adjustment PSS 

• The Patient Care WG reviewed the updated PSS and approved to become an interested party instead of co-sponsor on April 12th

Patient Care will be an interested party rather than a co-sponsor.

If we need more clinical input, we can bring it back to Patient Care to request for co-sponsor. 

We will take it to next HL7 process. 

1) Risk Adjustment to Calculate Capitated Premium Payment vs. Risk Adjustment in Quality Measurement

2) Discuss Risk Adjustment Report data elements and structural requirements from Payer to Provider

Name of IG

Updated terms of risk to include further specific based on last week discussion. 

• Risk adjustment to calculate capitated premium payment
  • this will be what the scope will be focusing on on phase 1
• Risk adjustment in quality measurement
  • will bring to CQI meeting to see if the quality measure fall under this scope or under another IG.

PSS title and IG title does not need to match fully. 

Risk Adjustment Report

Review Risk Adjustment Report data elements table. See link.

Determine if we have all data elements, place hierachical 

lastClaim- does this need to be placed for each HCC code?

• May fall under business review
• May be added under supportingResource, rather than adding it to each HCC code
• claims can map to multiple HCC so would be difficult to see LastClaim
  • the information is being pulled from encounters
  • main information- provider, diagnosis codes, procedures, dates
  • claims- need to differentiate from encounters and X12 claims transactions
    • claims related from administrative data and claims from FHIR resource
    • Best to use information that is derived from claims
    • should exclude financial information from claims
  • need to also define encounter with provenance 
• Instead will place the lastClaim and lastDiagnosis to be represented under the supportingResource.
• will remove it from the column

• Condition- would still need to enter known diagnosis, because it is not evident what information from the claim is related to the HCC
• Start with the diagnosis that the provider should be aware of
• Can you send diagnosis code that is clinically important but not as a risk adjustment issue?
  • should allow it and not prohibited
  • may be seen as an exception
• Need to consider evidence that is available at the time the report is ran. 
  • workflow should allow it to run ad hoc 

Conditions

• If suspected diagnosis but do not have a parent HCC code, you should be allowed to add the diagnosis code
• Suspected diagnosis should be optional to add any of the supporting evidence
  • allow field for ability to add supporting evidence
• If include it to in addition to the encounter, can provide full picture to provider on the condition

lastDateofService

• does this apply to condition or where does this fall?
• It may fall under the supportingResource

Note- Public calls for the Week of 4/26-4/30/21 will be cancelled due to Da Vinci Education Event.