hair:  Viet Nguyen, Yan Heras

Scribe: Phung Matthews
 

Minutes Approved as Presented 


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Meeting Minutes from Discussion

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






Announcement

HL7 Connectathon 28 Sept 13-15 

  • Registration is now available here
  • Last day to register is August 30th. 
  • Plan to hold a Risk Adjustment Track!

Visit the Da Vinci HL7 Connectathon page for quick highlights on each tracks. 

If going to participate- please register before the end of the month. 


Risk Adjustment IGContinuous Integration (CI) Build site: https://build.fhir.org/ig/HL7/davinci-ra

Review on Guidance in the continuous build.

  • If you have any suggestions/feedback/comments, please let us know. 

General Guidance

  • currently high level overview of risk adjustment. Brent will be helping with adding more background on the risk adjustment. 
  • Preconditions/assumptions section- 
    1. payer and provider establish contract
    2. risk model is defined
    3. payer determines risk coded/status
    4. responsibility of payer to ensure data used is present  in structured, retrievable format

Using payer and providers currently- do we need more generic such as consumer/producers? 

  • might need to have it general because you can't assume that producer is payer. 
  • change to consumer/producers and add note to show which one is which
    • producer is the one that generates the report and the consumer is the one that receives it

    • Brent Zenobia to Everyone

      possible consumers: primary care physicians; any provider under contract with the payer; self-insured employers; patients

      or even payers. Different payer business units (e.g. actuaries) might want to use these APIs for internal purposes

Discussion on provider vs practitioner- which is more appropriate? 

  • suggest to be consistent with the other IG. DEQM has it as a provider
  • practitioner used in Care Gaps due to it being its resource

When using the $report- the provider would know the patient id to pull the right patient. Logical ID for the payer system for that particular patient or group of patient, this will be a pre-condition. Before you can run the report, you will need to know the logical ID of the patient on the risk adjustment report side. How it is done, is not in the scope of this.

  • profile of FHIR MeasureReport, generated as FHIR bundle (bundle type will be a collection). 

If you are using HCC, it implies that you have applied the hierarchy. Suggest to use CC, condition category instead. Use of condition code might be confusing to others and may be assumed to be a diagnosis code. 

They are more like groupers, where it is pulling codes into categories. 

Final suggestion= use risk adjustment category, example HCC.

If reference, you will everything in that bundle. 

Question- currently Claim is not in US Core, would there be a need for claim FHIR resource to be returned as an evidence?

  • more likely to use encounters. May have a claim to produce an encounter. The encounter will provide the base of evidence.


Use of attribution- some areas are using extensively, some are not. Depends on the reason for the risk adjustment. However reasonable to assume that there is an out of band process to pull the patient information and permit you to pull the report. 

Risk Adjustment coding gaps 

In US Core Condition- morbid obesity- date needs to be switch from 06012020 to 20200601.

Typically it has to be a face to face encounter between provider and patient. 

In EvaluatedResource- is the supporting evidence. 

Should there be three different encounters due to each date?

Can't use last year encounter as evidence. Need the encounter of this year if collecting this year. 

Workflow example- has care management system. 

Suggest to add cloud based picture to show we do not worry about how the payers are pulling the reports on the back end. 

Daniel- suggest to not use the producer term as it can relate to brokers on the insurance end.

Linda- maybe have it as client FHIR server

Please review page and provide any feedback. 

Need to represent condition category as a FHIR resource condition, other than just represent the codes for the condition and pointing it to the condition category. Example how to make HCC code 08 be a FHIR resource. How to document it and associate it with the patient.  


Discussion

Continue with business requirement and FHIR analysis discussion:



Connectathon Planning







ManagementNext Agenda



Adjournment
adjourned at 03:57PM ET

Attendees

Present

Name

Affiliation


PresentNameAffiliation
PresentNameAffiliation
PresentNameAffiliation
  •  
Viet Nguyen
Stratametrics
  •  
Dale Davidson

  •  
Rachel Foerster

  •  
Kimberly Bradbury
  •  

Yan Heras



  •  
Karl EverittEpic
  •  
Tim McNeil

  •  
Steve Gasiorek
  •  
Gini McGlothin
BCBS Alabama
  •  
Thomson Kuhn

  •  
Leah Hannum

  •  
Daniel Tam
  •  
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
  •  
Donielle Williams




  •  
Anna Taylor
MultiCare
  •  
Mariel Brechner

  •  

Khush Singh






  •  
Susan Langford
BCBST
  •  
Christopher Marchand

  •  
Pranathi K




  •  
Floyd Eisenberg


  •  
Madhurima DharCozeva
  •  
Vijay Sravani Thotakura




  •  
Susan Bellile
Availity
  •  
Kira Whitworth

  •  
Angie Finley




  •  
Brent ZenobiaNovillus
  •  
Travis Hendrix

  •  
Eric Liu




  •  
Amy Neftzger
Optum
  •  
Zahid Butt

  •  
Kim Faison




  •  
Frank

  •  
Khushwinder Singh

  •  
Tushar Shah





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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