FHIR initiative aims to improve accuracy of risk-based adjustment

New use case seeks to fill gaps so payers and providers can document patient needs

A version of this story previously ran in the HL7 Quarterly Newsletter.

With healthcare now transitioning to value-based care, more payers are being reimbursed based on the healthcare needs of their patients, a practice known as risk adjustment.

Accurate assessment of risk depends on providers and payers obtaining a complete and accurate picture of patients’ acuity – it’s critical to ensuring proper reimbursement, effective cost management for high-risk members, and delivering high quality care.

The Da Vinci Project has started work on a new standard to facilitate information sharing in this area – that will help alleviate provider burden in dealing with potential missing gaps and assist payers by standardizing how risk adjustment gaps are communicated for patients.


Challenges in risk adjustment currently lies in the communication of potential missing risk adjustment data, which may be either done differently and sometime not at all by payers.

Inaccurate risk adjustment can cause inadequate payment to payers that don’t have enough information to understand and substantiate patients’ true condition and cost of care. Total underpayments for all causes were reported to be nearly $7.5 billion in Fiscal Year 2020 by the Centers for Medicare & Medicaid Services,

The traditionally manual process involved in risk adjustment can be facilitated with standard protocols that help facilitate the communication of a patient’s risk-adjusted conditions, which ensures more accurate assessment of conditions that should impact the cost of covering that patient under value-based contracts.

The new Da Vinci Project workgroup, which began work on developing the use case recently, hopes to have a first version of a standard for trial use ready for ballot early in 2022.

Public calls for the workgroup are now underway, and participants have carved out the data elements needed for the use case. It’s now working on FHIR gap analysis and refining the FHIR resources that can be used in the implementation guide. Currently, the group is looking at using Measure Report and Measure resources.

The working group has started building the implementation guide as a Continuous integration (CI) build and added examples under the artifacts section.

Currently, no FHIR implementation guide exists to standardize the format for the way in which risk-based coding gaps are communicated between payers and providers. The goal for this implementation guide is to provide a standard for adopting and communicating risk-based coding gaps to better inform clinicians of opportunities to address patient’s risk-adjusted conditions, and conversely, it will better enable payers to communicate risk-adjusted information to providers.

Benefits from developing this standard can be seen by all players in the industry. Many believe it will result in improved workflow for payers and decrease the need to seek patient records, while providers will benefit by having a standardized communication format from all payers, rather than trying to interpret multiple reports from different payers.

The project is reviewing the use of specific triggers and exchange methods and interoperability standards, and some FHIR resources to verify and facilitate documentation that supports risk adjustment, HCC models and version.

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