What is HEDIS and what does it mean to you?
You’ve probably heard of the acronym HEDIS – but what does it stand for and what does it mean to you? The Healthcare Effectiveness Data and Information Set – HEDIS — was created by the National Committee for Quality Assurance (NCQA) to measure the clinical quality performance of health plans.
What is the HEDIS system and what does it measure?
The Healthcare Effectiveness Data and Information Set ( HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.
What does HEDIS stand for in healthcare?
HEDIS (pronounced he´-dus) stands for Healthcare Effectiveness Data and Information Set. Employers and individuals use HEDIS to measure the quality of health plans. HEDIS measures how well health plans give service and care to their members.
What are the HEDIS quality measures?
What is HEDIS ®?
- HEDIS stands for Healthcare Effectiveness Data and Information Set.
- NCQA Specifications standardize performance to evaluate and compare health plan performance and quality.
- Required for ongoing NCQA Health Plan accreditation.
How is data collected for HEDIS?
HEDIS data is collected through a combination of surveys, medical record audits, and claims data. The data collected provides information regarding customer satisfaction, specific health care measures, and structural components that ensure quality of care.
How does HEDIS reporting work?
HEDIS measures how well health plans give service and care to their members. Here's how it works: Health plans collect data about their performance on certain services and types of care. For instance, the plan keeps track of how many children get immunizations.
What are the 5 domains of care for HEDIS?
HEDIS measures clinical quality and customer service, requiring standardized reporting under 5 domains of care:Effectiveness of Care.Access/Availability of Care.Experience of Care.Utilization and Risk Adjusted Utilization.Health Plan Descriptive Information.Measures collected using Electronic clinical data Systems.
What is a good HEDIS score?
For those in the eye care industry, receiving excellent HEDIS scores can be financially beneficial, while also improving the quality of care. CMS uses a 5-‐star system to rate Health Plans, with 1 star being “poor” and 5 stars being “excellent.” Bonuses for high star ratings range from 1.5 percent to 5 percent.
How are HEDIS scores calculated?
How Are Rates Calculated? HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of both administrative data and a sample of medical record data.
What are examples of HEDIS measures?
Examples of HEDIS® measures are Comprehensive Diabetes Care, Childhood Immunizations, yearly Well Child Exams for Children Ages 3-6 and yearly Adolescent Well Care Exams.
Who submits HEDIS data?
NCQANCQA collects HEDIS data from health plans, health care organizations and government agencies. Data are used to improve HEDIS measures and the health care system. Visitors to this page often check HEDIS FAQs, QRS FAQs, or ask a question through MyNCQA.
What are the 2022 HEDIS measures?
NCQA introduced race and ethnicity stratifications to five HEDIS measures including colorectal cancer screening, controlling high blood pressure, Hemoglobin A1c control for patients with diabetes, prenatal and postpartum care, and child and adolescent well-care visits.
Who is required to report HEDIS measures?
All SNP and MMP PBPs must report the HEDIS measures in Table 3. If a contract has multiple qualifying PBPs, then each qualifying PBP in the contract must report the measures in Table 3 in a separate submission. MMPs and contracts with SNP PBPs do not have to report any additional PLD files.
Why do payers care about HEDIS?
Health plans require HEDIS medical record review to measure performance on important dimensions of care and service. Payers participate in HEDIS reviews to improve their Medicare Advantage plan quality measurements, known as Star Ratings.
Does HEDIS apply to Medicare?
Generally, HEDIS measures span five domains including effectiveness of care, access or availability of care, experience of care, utilization and relative resource use, and health plan descriptive information. Commercial, Medicare, and Medicaid health plans rely on HEDIS measures to compare health plan quality.
Is HEDIS mandatory?
Q: Is my participation in HEDIS mandatory? A: Yes. Network participants are contractually required to provide medical record information so that we may fulfill our state and federal regulatory and accreditation obligations.
What are the HEDIS measures for 2022?
For MY 2022, HEDIS added three new measures, retired three measures/indicators and changed seven existing measures....Additions to HEDIS in 2022Advance Care Planning. ... Antibiotic Utilization for Respiratory Conditions. ... Deprescribing of Benzodiazepines in Older Adults.
Are HEDIS measures publicly reported?
HEDIS Measures Prenatal Depression Screening and Follow-Up (PND-E). Postpartum Depression Screening and Follow-Up (PDS-E). 2023 The following measures reported using ECDS will be publicly reported for MY 2023: Depression Screening and Follow-Up for Adolescents and Adults (DSF-E).
What is the point of a HEDIS audit?
The HEDIS Compliance Audit™ helps ensure accurate, reliable data that can be used by employers, consumers and government to compare health plans. NCQA licenses organizations and certifies individuals affiliated with licensed organizations to conduct audits using NCQA's standardized audit methodology.
What is HEDIS coding?
Developed by the National Committee on Quality Assurance (NCQA), the Healthcare Effectiveness Data Information Set (HEDIS) is a tool to assess the performance of health plans based on the quality of care and services provided to their members.
What is HEDIS in healthcare?
They report the data to the National Committee for Quality Assurance (NCQA), which rates health plans based on more than 90 measures across six areas of care. Health plans use HEDIS to see where they are performing well, and where they need to improve. Employers and consumers can also let you use HEDIS measures when deciding what health plan ...
What does hedis stand for?
HEDIS. HEDIS (pronounced he´-dus) stands for Healthcare Effectiveness Data and Information Set. Employers and individuals use HEDIS to measure the quality of health plans. HEDIS measures how well health plans give service and care to their members.
Can a plan be accredited by HEDIS?
Plans that meet a certain HEDIS score may become "accredited."
What is HEDIS in healthcare?
HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance. HEDIS Measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes. SNPs can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement, and provide a set of measurement standards that allow comparison with other plans. Data allow identification of performance gaps and establishment of realistic targets for improvement.
What is HEDIS measurement?
HEDIS Measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes. SNPs can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement, and provide a set of measurement standards ...
What is HEDIS?
HEDIS stands for Healthcare Effectiveness Data and Information Set. It was developed by the National Committee for Quality Assurance (NCQA) as a way to monitor the performance of the nation’s health plans. This retrospective review measures how well health plans perform on a wide variety of performance measures that are reviewed and set annually.
How is HEDIS data collected?
There are three ways that HEDIS data is collected. Administrative Data is obtained through claims databases of health plan representatives. Hybrid data is information that is taken from the claims database and review of medical records. Finally, Survey Data is obtained from both member and provider surveys.
Do you need help with your HEDIS tasks?
If you are starting to fall behind on your HEDSI projects, or simply do not have the time or personnel to dedicate to the massive task, Chart Review Nurses can help! We work to connect qualified nurses with health care providers that need assistance with their HEDIS tasks. We can work on a project by project basis, or take over all of your HEDIS activities. From chart abstractions to coding and reporting, Chart Review Nurses can help get the job done. Visit Hedis Nurses or call (877) 328-2343 to learn more or get started!
Best Practice and Measure Tips
Best practice to increase closure of gaps and provide details for member exclusions is to:
Measure Exclusions
Exclusions: Exclusions are either Optional or Required. An exclusion will remove member from the measure denominator based on a diagnosis and/or procedure captured in their claim, encounter and or pharmacy data.
Measure Codes
The National Committee for Quality Assurance (NCQA) uses a “Value Set Directory” to organize associated codes for each measure.
Measure Medications
Denominator: Number of members who qualify for measure criteria, based on NCQA technical specifications.
When does HEDIS work talk place?
HEDIS work takes place all year, but there is a specific timeframe in place. In Q1 of every year, providers will be contacted with requests for medical records. The data must then be collected and a chart abstraction will take place, typically on or before May of that same year. That might not seem like much work, but if you fall behind on chart abstractions or other HEDIS work and leave it to the last minute, you can find yourself under the gun.
How are HEDIS sores used?
You know HEDIS scores are important, but how are they actually used? Well, state purchases actually use this data to evaluate how effective health insurance providers are with their preventative health outreach. Physician scores are also used to provide evidence of preventative care. These scores are considered for physician profiling and other incentive programs .
What is the Healthcare Effectiveness Data and Information Set?
HEDIS is a measurement tool that is utilized by health plans to evaluate member satisfaction and performance. It is administered and managed by the National Committee for Quality Assurance (NCQA) and new measures are introduced and updated on an annual basis. These rates are becoming more important every year and are something that you need to stay on top of.
Tips for Managing Payer Requests During the Upcoming HEDIS Review Season
In working with payer record reviews, several practical strategies have emerged to minimize payer-provider abrasion and reduce operational costs. Providers should take a proactive approach and follow these three tips:
How Your Release of Information Vendor Can Help
At MRO, we utilize our industry knowledge and “easy to work with” approach to create partnerships with payers and their vendors to streamline the processing of HEDIS Review, Medicare Risk Adjustment and Commercial Risk Adjustment projects.
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In his role at MRO, Ford serves as a liaison between MRO’s healthcare provider clients and payers requesting large volumes of medical records for purposes of post-payment audits, as well as HEDIS and risk adjustment reviews.
What does a HEDIS nurse do?
HEDIS nurses focus solely on using HEDIS measuring criteria to review health plans in accordance with healthcare facility practices and patient experiences. Here are some specific examples of the types of job responsibilities HEDIS nurses have:
What is the purpose of discussing findings with HEDIS administrators?
Discussing findings with HEDIS administrators to make decisions about a healthcare facility and ways to improve patient care
What is the benefit of coding in HEDIS?
Medical coding proficiency: HEDIS nurses can benefit from medical coding skills at it helps them find information using medical codes and sort through documents or patient information.
Why is attention to detail important for a HEDIS nurse?
Attention to detail: HEDIS nurses can benefit from having excellent attention to detail as it enables them to catch important details about a patient's health and the quality of the care they received to determine whether they need to reevaluate a patient's health plan.
Why do hedis nurses need curiosity?
Curiosity: HEDIS nurses need a degree of curiosity to investigate different health conditions, plan information and care trends to figure out why a patient's health changed.
What is a HEDIS VSD?
The HEDIS Value Set Directory (HEDIS VSD), published as part of HEDIS Volume 2 and Volume 3, crosswalks HEDIS measure specifications to third-party medical and billing codes, including, but not limited to, CPT ® by the American Medical Association and Uniform Billing Codes by the American Hospital Association.
Do vendors need a license to use HEDIS?
Vendors and consultants that want to use HEDIS measure specifications for commercial purposes (further described below), or for any external reproduction, distribution or publication of measure specifications, must obtain a commercial-use license with NCQA. Use of a vendor or consultant’s measure logic may need to be validated through NCQA’s Measure Certification program.
What is HEDIS survey?
HEDIS survey measures and standardized surveys from the Consumer Assessment of Healthcare Providers and Systems (CAHPS ®) program.
What is a VSD in HEDIS?
The Rules for Allowable Adjustments are included in the HEDIS Volume 2 publication after the applicable HEDIS measure specifications. NCQA’s HEDIS Value Set Directory (VSD) includes the necessary third-party codes for use with adjusted measure specifications.
What is CAHPS trademark?
CAHPS ® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Best Practice and Measure Tips
Best Practice and Measure Tips: How Can I Improve Hedis Scores?
- Maximize use of codes: Only codes will close gaps for Administrative Measures.
- Submit claim/encounter data for every service in an accurate and timely manner.
- Some measures collect more than one data element. Submit codes required for all elements.
- Document medical and detailed surgical history with dates and use of appropriate coding. (Example: Documentation of Hysterectomy without reference to TOTAL, Radical, etc. will not …
- Maximize use of codes: Only codes will close gaps for Administrative Measures.
- Submit claim/encounter data for every service in an accurate and timely manner.
- Some measures collect more than one data element. Submit codes required for all elements.
- Document medical and detailed surgical history with dates and use of appropriate coding. (Example: Documentation of Hysterectomy without reference to TOTAL, Radical, etc. will not exclude member fr...
Measure Exclusions
- Exclusions are either Optional or Required. An exclusion will remove a member from the measure denominator based on information captured in claims, encounter, pharmacy, and/or enrollment data. 1. Optional exclusions: Some measures allow using an exclusion based on measure compliance. If the member is not compliant, the optional exclusion can be used. 2. Required exc…
Measure Codes
- The National Committee for Quality Assurance (NCQA) uses a “Value Set Directory” to organize associated codes for each measure. Measure Codes listed for each measure are not all inclusive and subject to change based on the current NCQA Specifications for each measure. Below are common value sets for quick reference: 1. Telephone visits: Eligible measures will reference the …
Hedis Terminology
- Anchor dates: A measure may require a member to be enrolled and to have a benefit on a specific date.
- Continuous enrollment:Specifies the minimum amount of time that a member must be enrolled in an organization before becoming eligible for a measure. It ensures that the organization has enough time...
- Anchor dates: A measure may require a member to be enrolled and to have a benefit on a specific date.
- Continuous enrollment:Specifies the minimum amount of time that a member must be enrolled in an organization before becoming eligible for a measure. It ensures that the organization has enough time...
- Denominator– Number of members who qualify for measure criteria, based on NCQA technical specifications.
- Element– Measurable way a HEDIS measure is broken down and defined. Also referred to as a sub-measure.