2021-04-22 Risk Adjustment Use Case Meeting

Da Vinci FHIR Education and Implementation event

April 26th- April 30th

Register here

Last Day to Register April 22, 2021.

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 

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

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?

• Stick to member information- provider ask what you have for the specific member and payers will submit or expose what they have available specific to the use case
• might be similar to what Care gaps is using in the GIC IG- 

  http://build.fhir.org/ig/HL7/davinci-deqm/OperationDefinition-care-gaps.html

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

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