An organization can enter data manually into IDSS during the 2020 reporting period. However, this will trigger a validation warning. It is important to be able to explain to anyone that conducts a HEDIS audit why that warning occurred.

Yes. Even though NCQA is not releasing Health Plan Ratings for 2020-2021 due to the COVID-19 Pandemic, accredited commercial and Medicaid plans still need to submit their HEDIS measures to meet their annual reporting requirements. Organizations will not be rated on the measures, but they are still required to submit the required HEDIS measures as usual.

HEDIS rates can be calculated in two different ways, with administrative or hybrid data. Administrative data is claim or encounter data that is submitted to the health plan. Hybrid data includes a mix of administrative and medical record data.

There are several ways that you can prepare for HEDIS record retrieval. First, you should prepare your HER/EMR system to ensure that your systems and workflow are configured correctly. Next, you should create a collection strategy with your vendors. That means defining roles, setting expectations, and addressing potential issues upfront. Last, but not least, you should also prepare your providers. Notify them of any upcoming retrieval efforts at least 2 months in advance so that they have time to prepare. Then, follow that up with regular reminders leading up to when you plan to start collecting records. By following these tips, you can better collect and retrieve records for HEDIS reporting.

The effectiveness of HEDIS guidelines is very dependent on provider participation. If you want to better facilitate the HEDIS process there are a few active steps you can take. These include:

• Increase member satisfaction by improving patient engagement
• Provide necessary care within designated timeframes
• Provide incentives to use self-management tools
• Document all patient care accurately in their medical record
• Create reimbursement strategies that increase provider collaboration
• Properly code all claims regarding patient care
• Respond to requests for information in a timely manner

There are a few ways that you can improve HEDIS scores. This includes:

• Submitting a claim for every service rendered
• Ensuring the chart documentation reflects all of the services being billed
• Bill for all delivered services
• Make sure that all claim and encounter data are submitted timely and accurately

If you need help improving your HEDIS scores, contact Chart Review Nurses today for assistance.

Once all of the medical records have been collected, data abstraction can occur. When abstracting records for HEDIS measures, you need to do a detailed analysis and review of medical charts, insurance claims for hospitals, office visits (both sick and well), and other procedures provided to determine the quality of care measures. Essentially, when abstracting records for HEDIS measures, you are pulling out the raw data so it can be put into the HEDIS measure framework and scored.

One of the best ways to improve HEDIS retrieval rates is to track retrieval and abstraction efforts on a weekly basis. This will help you see what trends are appearing and how successful your retrieval partners have been in regards to obtaining records. If your retrieval partner is not having much success, you may want to consider switching to another provider that has more experience and a bigger network.

There are several ways in increase HEDIS rates. These include:

1. It is important to provide accurate and thorough documentation. Ensure that all services provided to a patient are documented in their medical records. It is also important to double check these medical records to ensure that there are no mistakes or omissions.
2. Meeting deadlines for services is also important to raise HEDIS rates. This also includes preventative care and other follow up measures and services.
3. Shifting focus to preventative screenings and providing superior patient care is also important for increasing HEIDS rates. One way to do this is by looking for gaps in well-visits, especially for individuals that are considered high-risk. You should also ensure availability of services by addressing any issues that arise in regards to scheduling appointments.
4. Including population health management and patient engagement into you plan is also essential for boosting your HEDIS scores. Payers benefit from offering support to provider networks. Direct outreach to engage patients is also encouraged. 

There are three main ways to increase Medicare STARS ratings. These include:

• Encouraging plan members to utilize their covered services: For patients who are healthy, this includes annual physical exams, vaccines, and preventative screenings. Patients with chronic diseases should maintain the proper frequency of visits and providers should share tips on how to manage the patient’s illness properly.
• Focus on the user experience: The STAR rating system is weighted towards the members’ experiences so be sure to add convenience where possible. Take advantage of mobile apps or an intuitive website for bill pay, appointment schedules, etc.
• Increase communication: The STAR rating system also takes into account customer service, which is why communication is key. Offer chat support, online FAQs, and even a 24-hour phone number to ensure members can always get access to the information they need when they need it.

Reviewing and analyzing medical records can be overwhelming, but there are some steps that you can take to be successful. These steps include:

1) Receive and organize the medical records that you need

2) Determine which medical records are missing

3) Consult with health care providers to request any records that you are missing

4) Identify factors that cause alleged injuries or damages

5) Prepare the written reports that involves the findings and your analysis of the medical records

The Healthcare Effectiveness and Data Information Set (HEDIS) includes over 90 measures. These measures are updated every year, but in 2019, there are currently 98 HEDIS measures.

The measures are spread across six different domains of care, including Effectiveness of Care, Experience of Care, Utilization and Risk Adjusted Utilization, Access/Availability of Care, Health Plan Descriptive Information, and Measures Collected Using Electronic Clinical Data Systems.

No. Due to the COVID-19 Pandemic, NCQA is not releasing 2020-2021 Health Plan Ratings for any product line. However, accredited commercial and Medicaid plans are still required to submit HEDIS and CAHPS measures to meet their annual reporting requirements.

A chart abstraction is the process of obtaining important information from medical records and transcribing the select information into specific fields within a new electronic health record system. This manual data entry effort is required to convert paper medical records into electronic health records.

EQR stands for External Quality Review, and an EQRO is an External Quality Review Organization. An EQR is the analysis and evaluation of a managed care organization (MCO) that is conducted by an EQRO. These reviews examine different quality measures, including quality of care, timeliness, and access to health care services that an MCO or contractor offers to Medicaid patients.

Stemming from the HEDIS measures, the Centers for Medicare and Medicaid Services (CMS), created a star rating system. This system rates how a health plan’s Medicare Advantage program performs across the various HEDIS quality measures on a five star scale. Based on the star ratings, health plans are eligible to be paid bonuses.

There are six domains of care that encompass HEDIS quality measures. They are:

• Effectiveness of Care
• Experience of Care
• Access/Availability of Care
• Health Plan Descriptive Information
• Utilization and Risk-Adjusted Utilization
• Measures Collected Using Electronic Clinical Data Systems.

All of the data used for HEDIS reporting must be audited. Plans should complete the Audit Roadmap for each source of data being considered for use and work with their auditors to ensure the approval of each source.

There are three different ways that HEDIS data is collected. Administrative Data is collected from claims databases. Hybrid Data is collected from both medical record reviews and claims databases. Finally, Survey Data is HEIDS data that is gathered from member and provider surveys.

There are 6 domains of care for HEDIS. They are:

• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Risk-Adjusted Utilization
• Health Plan Descriptive Information
• Measures Collected Using Electronic Data Systems.  

There are three sources of data that are used for HEDIS. These three sources include administrative, hybrid, and patient survey.

Administrative data collection measures the claims for procedures, hospitalizations, medical visits, and pharmacy data.

Hybrid data collection occurs if there is more data needed to create a better overall picture. In this case, administrative data is combined with that member’s medical record information.

Patient survey is a method for HEDIS data collection that focuses on the patient experience. This data is collected via a survey conducted by the Consumer Assessment of Healthcare Providers and Systems (CAHPS).

The first part of a HEDIS Compliance Audit is Information System Capabilities. This looks at the organization’s overall information systems capabilities for fathering, storing, and analyzing health information.

Part two of the HEDIS Compliance Audit looks at HEDIS Specific Standards. During this portion of the audit, the auditor reviews the information system and then designs appropriate verification audit steps for various HEDIS measures. This part of the audit addresses compliance with specified reporting practices for several HEDIS domains, including Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Risk-Adjusted Utilization, Health Plan Descriptive Information, and Measures Collected Using Electronic Clinical Data Systems.

During HEDIS review, medical records need to be collected. These records are used by health plans and the NCQA to analyze and help improve the healthcare system. HEDIS medical record collection plays a large role in the care that patients receive and HEDIS Nurses is one of the companies that can assist with medical record collection for HEDIS. In addition to medical record collection for HEDIS, we can also assist with chart abstractions and other HEDIS work.

The HEDIS audit final report shows the plan’s results for the measures that were audited. Each measure that is audited gets assigned one of the following outcomes:

• Reportable (rate or count)
• NA (small denominator)
• NB (benefit is not offered)
• NR (not reported)
• NQ (not required to report)
• BR (biased rate)
• UN (unaudited)

If you need help further understanding your HEDIS audit results, contact HEDIS Nurses today!

A HEDIS Compliance Audit examines whether or not an organization has the capability to process medical, member, and provider information accurately in order to provide automated performance measurement. This includes HEDIS reporting.

A HEDIS Compliance Audit will look at an organization’s:

• Information practices and control procedures
• Sampling methods and procedures
• Data integrity
• Compliance with HEDIS specs
• Reporting and documentation

A typical HEDIS calendar follows the timeline below:

• January – May: Clinical Quality staff begins requesting medical records from the necessary providers
• June: HEDIS results are reported to the National Committee for Quality Assurance (NCQA)
• July: The NCQA releases the commercial edition of the Quality Compass
• August: Project health plan ratings are released
• September – October: Quality Compass for Medicare and Medicaid are released and final health plan ratings are posted on the website

If you are struggling to keep up with this HEDIS calendar, call HEDIS Nurses for help!