Chair:  Viet NguyenYan Heras

Scribe: Phung Matthews
 

Minutes Approved as Presented 


This is to approve minutes via general consent. "You have received the minutes. Are there any corrections to the minutes? (pause) Hearing none, if there are no objections, the minutes are approved as printed."

Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link(if not child)
ManagementReview ANSI Anti-Trust Policy






Announcement

Da Vinci FHIR Education and Implementation event

April 26th- April 30th

Register here

Last Day to Register April 22, 2021.


HL7 Process Update

FHIR Risk Adjustment PSS 

  • FHIR Management Group (FMG) approved the PSS on 4/21

PSS update-

  • because we changed the Sponsor group, we had to start at the beginning of approving the PSS and bring it to steering committe
  • Next going to US Realm 



Discussion

Continue discussing Risk Adjustment Report data elements and structural requirements from Payer to Provider

Phase 1- really focusing from Payer to Provider. 

Visual on data elements that may be required for the Payer to Provider report. Not intended to be what a report should look like. 

Adding Member information, provider information, Risk adjustment model and version, clinical evaluation date, Historic conditions, suspected conditions (based on hierarchical structure) 

Status- include confirmed or non-confirmed

Condition- mentioned previously it was important to capture diagnosis codes. For each condition, may have last date of service.  

For each HCC code, have diagnosing provider, current provider and supporting evidence. 

Suspected conditions- include supporting evidence for the condition

Provider element- how do you link the provider and member. Is the provider to be the PCP or attributed to member. 

  • example- if specialist like an oncologist- will the specialist be listed or PCP?

Business scenario added to confluence- for more examples

Plan- how is this being represented, as many plans can change at any time. Would you add the most recent plan? 

Filtering on API- How common is it for providers to pass parameters for certain elements, so that the payer will need to expose it for query purposes?

Are there gaps on the actuarial models- based on real scenarios?

  • Is there an application outside of risk adjustment- that has a concept of gaps that fit within this use case?
  • for example DXCG models.
  • may be out of scope for this as of now

Clinical evaluation period- scenario is provider wants to get an HCC back on a specific period. 

  • Is there a better name than clinical evaluation period? Does it differ or affect the Run Out period?
  • what would be the best definition?
    • period during which risk adjustment of which encounter can conducted and documented with expectation of submission for risk adjustment purposes
  • there are nuances on when claims are accepted by payers. May be more geared toward the payers to determine that date period

Revenue period- The year you are adjusting for payment. Is this appropriate term?

  • Revenue seem appropriate. There could be instances that they are using the information for population health and not revenue
  • If you specific the clinical evaluation and risk model- then you should already know the revenue period.
  • if revenue period is strictly based on other data elements information (clinical evaluation, risk model, risk version) then why include it? 
    • there is always a relationship with clinical evaluation and risk model.
    • might be redundant to have- so may be best to remove it.

Run Out period- As long as you can know which gaps period it falls under then you may not need run out.

  • Payer run out period vs CMS run out period
    • payer may need to adjust based on their policy- date detemine when you can last submit information
    • adding this information- to allow provider to know when they can take actions until
    • action date should be communicate by payer to provider by different channel as the date would be the same regardless of the what gaps are found

Does query need parameter for the calendar year? Ie last period or this period? As you may need to know if the diagnosis was made last year. 

  • May allow query to find HCC codes or gaps- based on the clinical evaluation period or based on the actionable due date
  • Can provide date as parameter, then another ask if
    • want to see everything that was actionable between that date
      • results could be submittal
    • all HCCs (closed and open)- fall between beginning and ending of clinical evaluation period
      • status of confirmed, non-confirmed and pending








ManagementNext Agenda

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


Adjournment
Adjourned at 4:02PM ET

Attendees

Present

Name

Affiliation


PresentNameAffilitation
PresentNameAffiliation
  •  
Stratametrics
  •  
Dale Davidson

  •  


  •  


  •  
Karl EverittEpic
  •  


  •  
BCBS Alabama
  •  
Thomson Kuhn

  •  


  •  
Providence St. Joseph
  •  
Patty Craig

  •  


  •  

Peter Muir



  •  
Nick Radov

  •  


  •  
Optum
  •  
William Harty

  •  


  •  

Brian Murta

Centene
  •  
Deidre Sacra

  •  


  •  
POCP
  •  
Jay Baker

  •  


  •  
POCP
  •  
Joseph Quinn HSX
  •  


  •  
Phranil MethaHealow
  •  
Cigna Evernorth
  •  


  •  
MultiCare
  •  
Mariel Brechner

  •  


  •  
BCBST
  •  
Christopher Marchand




  •  


  •  
Peter Muir




  •  
Availity
  •  






  •  
Brent ZenobiaNovillus
  •  






  •  
Optum
  •  






  •  
Frank

  •  







Action items

  •  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.

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