Engineering a Defensible Suspect-Condition Pipeline (Identify Validate Capture)

Suspect-condition workflows are deceptively simple to prototype and surprisingly hard to make defensible . Anyone can flag "this member might have HCC X." Building a system whose output survives a RADV audit is a different problem. This is a walkthrough of the three stages and the engineering decisions that matter at each. Stage 1: Identify Identification is pattern detection over a member's clinical record — labs, medications, prior diagnoses, utilization. Model it as a set of rules or features that emit candidate HCCs: def identify_suspects ( member ): suspects = [] if member [ " labs " ]. get ( " a1c " , 0 ) >= 9.0 and " insulin " in member [ " meds " ]: suspects . append ({ " hcc " : " HCC38 " , " trigger " : " a1c>=9 + insulin " }) if member . get ( " egfr " ) and member [ " egfr " ] < 30 : suspects . append ({ " hcc " : " HCC326 " , " trigger " : " egfr<30 " }) return suspects The temptation is to maximize recall here — flag everything. Resist it. Every unvalidated suspect you generate is downstream work and downstream risk. Stage 2: Validate (the stage that actually matters) Validation attaches evidence to each suspect and scores its defensibility. This is the difference between a documentation opportunity and an audit liability. def validate ( suspect , member ): evidence = collect_evidence ( suspect [ " hcc " ], member ) # labs, rx, prior dx suspect [ " evidence " ] = evidence suspect [ " confidence " ] = score_evidence ( evidence ) suspect [ " defensible " ] = suspect [ " confidence " ] >= 0.7 return suspect Key design rule: a suspect with an empty evidence array should never reach a coder. Make that a hard gate, not a soft warning. Under CMS-HCC V28 and current audit posture, a captured-but-unsupported diagnosis can be extrapolated across a contract into a real clawback — so "defensible by default" is the right engineering stance. Stage 3: Capture Capture routes validated suspects to the right human with the evidence inline, so the clinician or coder can