Chair:  Viet Nguyen, Yan Heras

Scribe: Phung Matthews
 

Minutes Approved as Presented 


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Agenda Topics

Agenda Outline

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Meeting Minutes from Discussion

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






Announcement

The meeting on July 22nd will be cancelled due to CMS Connectathon

Participant session for the CMS connectathon- at 4PM ET. 


HL7 Process Update

FMG approved the Da Vinci Risk Adjustment FHIR IG Proposal on June 30th

Next deadline is October for the NIB- intention to Ballot. 


Discussion

Continue with business requirement and FHIR analysis discussion

  • HCC Gaps and Hierarchies (Brent Zenobia)

Big thank you to Brent for preparing this HCC gap and hierarchies. 

Slide deck

Presentation to demonstrate the subtlety of HCC and hiearchies. 

Hiearchies- CMS v 24 2021- organized by clinical data

  • Can have situation where HCC codes do not supersede each other and are lower levels in the hierarchy. 
    • example HCC 161 can be in more than one clinical group
    • common to redraw hiearchies and keeps the superceding values. but may not be organized as clinical data but more computational data
      • example HCC 106 can be in multiple group but is not superceded by any other codes
  • typically one gap per HCC 
  • for HCC gap, there are two different ways to display it. 
    • one view is display in the EHR so provider can take action on it
    • another view is displayed for performance rate, how many HCC you closed to sum of active HCC gaps.
  • Open gaps- no confirmed
  • closed gaps- confirmed
  • active and inactive term- seem on the payer side. 

Scenarios with hierachies

  • A- Payer always apply the hierarchies, provider will see most severe active open gap
  • B- Payer will not apply hierarchies and will send all HCC gaps (open and closed)
  • C- Payer will send all gaps and hierarchies but all a flag/tag so the provider can decide what they want to view/display

If always applying hierarchies, you may lose sight of open HCC gaps that is buried due to the superceded HCC gaps and miss the opportunity to close it. 

If not applying hierarchies, the HCC codes that should be superceded will continue to show up in the EHR, and only way to remove them is going in manually to close and invalidate each HCC. Brings burden onto the provider end. 

This scenario will send all the gaps, open and closed. Superceded HCC codes only work on close gaps.  Payer can flag the HCC codes as closed and superceded. Provider can then indicate in the filter to display which HCC gaps are left. 

To be superceded, you need a higher superior gap to be closed. 

Challenge- whether the payer should second guess what the provider wants to see. 

Best practice to have the filtering function on the provider side. EHR/SMART on FHIR should have the capability to implement a filter. 

 Scenario C- will have superceding rules on the payer side, how the flags are set up will be on the payer side.  

May need to have a standard on how the flags are set up as there could be many variations on the payers. 

This becomes trickier when looking at HCC gaps for performance gap rules. Depending on the rule and which HCC codes are inactivated based on rules, performance rate will be affected. 

Where the IG can help- if it can be used to display gaps and performance gaps and help provider have full display of HCC. 

  • provide mutual semantic on what the payers and providers understand on the HCC gaps. 
  • use the flag to allow the provider see it 
  • current ambiguity on what action is necessary for the provider as provider may not understand the financial implication of closing the gaps

Question- are current reports displaying the contract terms regarding the HCC risk adjustment?

  • There are variations among payers on reports, some may. 

May need to have a request for comments during the ballot period to seek comments on the performance rules. 

This is why it is imperative that we provide the provider the ability to invalidate gaps. 

May be more toward the STU2. 






ManagementNext Agenda

Next week meeting will start 15 minutes later. 


Adjournment
adjourned at 04:01PM

Attendees

Present

Name

Affiliation


PresentNameAffiliation
PresentNameAffiliation
  •  
Viet Nguyen
Stratametrics
  •  
Dale Davidson

  •  
Rachel Foerster
  •  

Yan Heras



  •  
Karl EverittEpic
  •  
Tim McNeil
  •  
Gini McGlothin
BCBS Alabama
  •  
Thomson Kuhn

  •  
Leah Hannum
  •  
John Graham
Providence St. Joseph
  •  
Patty Craig

  •  
Dave Foster
  •  

Peter Muir



  •  
Nick Radov

  •  
Bryan Briegel
  •  

Linda Michaelsen

Optum
  •  
William Harty

  •  
Preston Lee
  •  

Brian Murta

Centene
  •  
Deidre Sacra

  •  
Gary Dickinson
  •  

Phung Matthews

POCP
  •  
Jay Baker

  •  
Rob Reynolds
  •  

Vanessa Candelora

POCP
  •  
Joseph QuinnHSX
  •  
Shawn
  •  
Phranil MethaHealow
  •  

Ezequiel Morales

Cigna Evernorth
  •  


  •  
Anna Taylor
MultiCare
  •  
Mariel Brechner

  •  


  •  
Susan Langford
BCBST
  •  
Christopher Marchand




  •  
Floyd Eisenberg


  •  
Peter Muir




  •  
Susan Bellile
Availity
  •  
Kira Whitworth




  •  
Brent ZenobiaNovillus
  •  
Travis Hendrix




  •  
Amy Neftzger
Optum
  •  
Zahid Butt




  •  
Frank

  •  
Khushwinder Singh





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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