The Basics

If your DM program offers predictive risk modeling (and not all programs do), this standard specifies the information the program must be able to provide:

• Risk calculation models used;
• The evidence upon which the modeling is based;
• How the model was validated;
• How (and how often) the models are reviewed and updated; and
• What methodology the program uses to stratify and categorize the observed population..

Management Tips

We recommend that you create a distinct document for your predictive risk modeling process.  It should be a historical document, addressing the development of the model.  It should be descriptive, specifying such things as data sources, parameters, and variables.  Finally, it should be a prescriptive document, defining such things as required frequency of validation and method of validation.

URAC Accreditation Tips

The five elements of this standard each weigh 2. 

If your program does not offer predictive risk modeling, submit an attestation to that affect as your sole documentation.  If the program offers such modeling, submit a document that describes the variables, anticipated outcomes, processes for updating the model, and a validation protocol.  The protocol should include the source(s) and time frame of the data, processes for data integrity, and model validation processes.

For the onsite review, prepare a presentation of the model for the reviewer, including client reports.  The reviewer will interview the data analysts involved in producing the risk analyses.  The interview might include some of the following questions:

• When was this model developed?
• Who was involved in its development?
• What is the underlying evidence for the model?
• What are the model’s key variables?
• What are the data sources?
• Was the model tested before implementation?
• Please tell me about the implementation process for the model.
• How often do you validate the model?
• Do you hire a third-party to conduct or help with the validation process?
• Have you made any changes over time in the model?