Transcript Title

P0418 (10/09)
HEDIS®
HEDIS® requirements for Anthem, MDwise and
Managed Health Services
A Combined Managed Care Presentation
October 20-22, 2009
HEDIS® is a registered trademark of the National Committee for
Quality Assurance
Agenda
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Introduction of Managed Care Representatives
What is HEDIS
HEDIS Measures
Data Reporting
Chart Reviews
HEDIS Barriers
Missed Opportunities Flyer
Presumptive Eligibility and NOP
Anthem
Managed Health Services
MDwise
Questions & Answers
Drawing
Hoosier Healthwise
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HEDIS Overview
What is HEDIS?
 HEDIS – Healthcare Effectiveness Data and
Information Set
 National Committee for Quality Assurance (NCQA)
uses these performance measures for commercial,
Medicare, and Medicaid.
 HEDIS is the most used set of performance measures in
the Managed Care industry, developed and
maintained by NCQA.
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HEDIS Overview
 Majority of HEDIS is measures from administrative
results-claims, but some of the measures are pulled
from hybrid results-medical record review.
 Administrative data is calculated by a claim or an
encounter submitted to the health plan.
 Hybrid reviews are a random sample of member
medical records. Hybrid data can consist of
administrative data and a sample of medical record
data.
 Annual State mandated quality improvement initiative
required of all Managed Care Health plans.
 Retrospective review of medical care and services
from the prior year.
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HEDIS Overview
 Results from the HEDIS data collection serve as
measurements for quality improvement processes and
preventive health programs.
 HEDIS rates are used to evaluate the effectiveness of
a health plan’s ability to demonstrate an
improvement in preventive health outreach to its
members.
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HEDIS Overview
 Data is reported to NCQA in June of the reporting
year.
 Data reflects events that occurred during the
measurement year (calendar year).
 Example:
 HEDIS 2009 data is reported in June 2009.
 Data reflects events that occurred in January –
December 2008 (per specs)
 HEDIS 2009 = 2008 data
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HEDIS Overview
 Denominator – Eligible members of the population.
 Numerator – Members that meet the criteria of the
measure.
 Anchor Date – The specific date the member is
required to be enrolled to be eligible for the measure.
 Continuous Enrollment – The minimum amount of time
a member must be enrolled to be eligible for a
measure.
 Provider Specialty – Certain measures must be
performed by a specified provider specialty.
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HEDIS Score Barriers
 Claims not submitted due to members that have third party liability.
 Members that are assigned to the wrong Primary Medical Provider.
 Claims are submitted without the appropriate diagnosis or CPT
codes that will count towards the measures.
 The provider specialty does not count towards the measure.
 The member is not continuously enrolled.
 The services are not all documented in the members medical chart.
 All components of the required measure were not provided.
 New member and previous medical records are not obtained or
transferred when a member changes PMPs.
 Appointment availability when a member tries to schedule
preventive services.
 Appointment availability for new members on the PMP panel.
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HEDIS Measures – Hybrid Review
 Cervical Cancer Screening – CCS*
 Women 24 – 64 years of age who had a pap smear
during the measurement year or the two years prior
to the measurement year or have documentation
of a hysterectomy. The claim must have the
appropriate coding and with the appropriate
provider specialty to count toward the measure.
* OMPP Incentive Measure
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HEDIS Measures – Hybrid Review
 Comprehensive Diabetes Care – CDC
 Members 18 – 75 of the measurement year who
received an LDL – C screening, and care of diabetes
during the measurement year. The claim must have
the appropriate coding to count toward the measure.
 Required testing and documentation:
Hemoglobin A1c (Test and Result)
LDL – C Lipid screening (Test and Result)*
Retinal Exam (Dilated eye exam/Retinopathy)
Urine screening (ACE or ARB medication therapy)
(attention to Nephropathy)
 Blood Pressure Documented (<130/80) (<140/90)
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* OMPP Incentive Measure
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HEDIS Measures – Hybrid Review
 Well – Child Visits in the First 15 Months of Life – W15*
 Members 0 – 15 months of age must receive 6 or more well – child
visits with a PMP that document in the medical record the following:
 health and developmental history (physical and mental) i.e.
developmental questionnaires regarding sleep habits, feeding,
motor skills, teething, interaction with others, walks alone,
teething/chewing objects, and PCP observation.
 a physical exam i.e. general appearance, height, weight, heart,
lungs, abdomen, head circumference, deformities, reflexes
present, fontanels, and alertness.
 health education/anticipatory guidance i.e. injury prevention,
circumcision care, thermometer use, choking prevention,
bathing, car seat use, temper tantrums, and lead poisoning.
 The claim must have the appropriate coding and submitted with the
appropriate provider specialty to count towards the measure.
* OMPP Incentive Measure
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HEDIS Measures – Hybrid Review
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HEDIS Measures – Hybrid Review
 Well – Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – W34*
 Members 3–6 years of age in the measurement year must receive
one well – child visit with a PMP each year that documents in the
medical record the following:
 health and developmental history (physical and mental) i.e.
developmental milestones, disposition, communication with
others, vocabulary, independence with dressing, and toileting.
 a physical exam i.e. general appearance, height, weight, heart,
lung, abdomen, BMI percentile, vision, hearing, abuse/neglect,
eyes/strabismus, and alertness.
 health education/anticipatory guidance i.e. balance meals with
snacks, limit sweets, caution with strangers, second hand smoke,
childcare planning, bed time, friends, and limit setting.
 The claim must have the appropriate coding and submitted with the
appropriate provider specialty to count towards the measure.
 * OMPP Incentive Measure
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HEDIS Measures – Hybrid Review
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HEDIS Measures – Hybrid Review
 Adolescent Well – Care Visits – AWC*
 Members 12 – 21 years of age in the measurement year must receive
one well – child visits with a PMP that document in the medical
record the following (school physical, preventive care visits with a
Pap, or post partum visit):
 health and developmental history (physical and mental) i.e.
developmental questionnaires regarding social and emotional
development, school progress, physical activity, depression,
menarche, and peer relationships.
 a physical exam i.e. general appearance, height, weight, heart.
Lung, abdomen, tanner stage, BMI, head eyes, heart, lungs,
acne, and pap smears.
 health education/anticipatory guidance i.e. balanced meals,
sex education, safety, smoking, drug and ETOH avoidance,
regular exercise, breast self exams, seat belt use, suicidal
ideation, and partner selection.
 The claim must have the appropriate coding and submitted with the
appropriate provider specialty to count towards the measure.
* OMPP Incentive Measure
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HEDIS Measures – Hybrid Review
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HEDIS Measures – Missed
Opportunities
 A member comes in for a problem focused or sick visit
and per the HEDIS measure is in need of preventive
services; well child visit, immunizations, or a screening,
and these services were not provided at the visit.
 A member was in the office for a postpartum visit and per
the HEDIS measure is in need of a pap and the service
was not provided at the visit.
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HEDIS Measures – Missed
Opportunities
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HEDIS Measures – Hybrid Review
 Childhood Immunization and Lead Screenings – CIS
and LSC
 The health plan is looking for all childhood
immunizations and lead screenings to be
completed on or before the child’s second
birthday.
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HEDIS Measures – Hybrid Review
 Immunizations for Adolescents – IMA
The health plan is looking for a percentage of
adolescents 13 years of age who had the following
by their 13th birthday:
 one dose of meningococcal vaccine given on
or between the 11th and 13th birthday AND
 one tetanus, diphtheria toxoids, and acellular
pertussis vaccine (Tdap) given on or between
the 10th and 13th birthday OR
 one tetanus, diphtheria toxoids vaccine (Td)
given on or between the 10th and 13th
birthday.
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HEDIS Measures – Hybrid Review
 Controlling Blood Pressure – CBP
 Members 18 – 85 years old with a diagnosis of
Hypertension (High Blood Pressure) on or before
June 30th of the measurement year.
 Latest documented blood pressure during
measurement year; control of ≤ 140/90.
 The following information is pulled: problem list and
progress notes.
 If the member is pregnant during the measurement
year, the member is excluded for the measure.
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HEDIS Measures – Hybrid Review
 Cholesterol Management for Patients with
Cardiovascular Conditions – CMC
 Members 18 – 75 who were diagnosed with
Myocardial Infarction, Coronary Bypass Graft,
Coronary Angioplasty, Ischemic Vascular Disease
 Documentation of LDL drawn and LDL control < 100
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HEDIS Measures – Hybrid Review
 Body Mass Index – BMI
 BMI is a screening tool for obesity that will assist in
determining BMI– for – Age Percentiles
 Documentation for BMI percentiles for children <16
years old and BMI value for children >16 years old.
 Documentation of Educational materials, Nutritional
Counseling, Activity plans and education.
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HEDIS Measures – Hybrid Review
 Adult BMI Assessment – ABA
 The percentage of members 18-74 years of age
who had an outpatient visit and who had their
body mass index (BMI) documented during the
measurement year or the year prior to the
measurement year.
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HEDIS Measures – Hybrid Review
 Weight Assessment and Counseling – Children and
Adolescents – WCC
 There are 3 required components of this measure:
 Age 3 – 17 years old.
 BMI percentile or percentile graph must be
documented on all children less than 16 years old, BMI
value for over 16 years old will be accepted.
 Counseling and Nutrition in the form of discussion on
diet, anticipatory guidance for nutrition, or counseling
on nutrition.
 Counseling for Activity in the form of discussion of
current physical activities, counseling for increasing
activity, or anticipatory guidance on activity.
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HEDIS Measures – Hybrid Review
 Frequency of Ongoing Prenatal Care – FPC*
 Members who delivered a live birth on or between
November 6 of prior year to November 5 of measurement
year and were continuously enrolled 42 days prior to
delivery.
 Documentation of all prenatal visits.
 ≥81 percent of expected visits.
*OMPP Bonus Measure
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HEDIS Measures – Hybrid Review
 Prenatal and Postpartum Care – PPC*
 Members who had a live birth in the measurement
year who had their first prenatal visit within 42 days of
enrollment or during the first trimester.
 Postpartum Care*
 Members who had their postpartum visit on or within
21 – 56 days of delivery.
 The claims must have the appropriate coding and
submitted with the appropriate provider specialty to
count towards these measures.
*OMPP Bonus Measure
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Presumptive Eligibility and Prenatal
Measures
 For a limited time, a pregnant woman who has been
determined by a Qualified Provider (QP) to be ‘presumptively
eligible’ may receive ambulatory prenatal services while her
Hoosier Healthwise application is being processed.
 The Package is known as “Package P”.
 OMPP and the MCO’s worked jointly to develop a universal
assessment for pregnant women known as the Notification of
Pregnancy (NOP) to do the following:
 Identify health risk factors
 Monitor risk factors
 Increase the percentage of pregnant women
assessed during the first trimester
 Increase average birth weights
 Reduce smoking rates
 Reduce the number of pre – term deliveries
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Presumptive Eligibility and Prenatal
Measures
 Providers are reimbursed $60 for submission of valid NOP.
 Reimbursement is limited to one form per pregnancy.
 A valid NOP must be submitted within 5 calendar days
via the Web interChange.
 The pregnant member gestation must be LESS than 30
weeks gestation for NOP reimbursement.
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HEDIS Measures
 Follow up Care for Children Prescribed ADHD Medication – ADD*
 Members 6 – 12 years of age who receive a new prescription for
an ADHD medication (had a negative ADHD medication history
for 120 days prior) must receive a follow – up visit with a
practitioner with prescribing authority during the 30 – day
initiation Phase.
* OMPP Incentive Measure
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HEDIS Measures
 Follow up After Hospitalization for Mental Illness – FUH*
 Members 6 years of age and older as of the date of
discharge from an acute inpatient stay must receive
an outpatient visit with a mental health practitioner
within 7 days after the discharge.
* OMPP Incentive Measure
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Quiz
 What does HEDIS stand for?
 What are 5 of the OMPP bonus measures?
 What are 3 barriers that cause services not to count
toward HEDIS measures?
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MCO HEDIS Interventions
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Anthem
 HEDIS Summit conducted in January 2009. Successfully
disseminated knowledge on all aspects of HEDIS,
identified critical elements and best practices to improve
HEDIS performance
 Successfully developed three HEDIS workgroupsmember, provider, and data, focusing on strategies and
building on existing programs.
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Anthem
 Provider focused strategies:
 Aligned the Physician bonus program with the State’s P4P Program
including OB providers.
 Working on providing real time HEDIS data to physicians through
ManagedCare.com.
 Developed a plan to deliver “members with gaps in care” reports to
providers in person, by mail, or by fax, and assisting with tracking
mechanisms for preventive/well care appointments to capture
missed opportunities
 Incorporating age appropriate forms into current practice
guidelines
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Anthem
 Provider focused strategies
 Developed provider tool-Kits containing educational required
materials, forms, and preventive care codes, to assist network
physicians in utilizing best practices from around the country in order
to improve care to members; thus improving HEDIS performance.
 CRC field staff are receiving training to assist physicians and their
office staff to access and utilize the ManagedCare.com reports.
 Developing provider trainings via webinar and face to face contact
meetings
 Providing medical records feedback from current year HEDIS
abstractions
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Anthem
 Member focused strategies:
 Clinical Quality Health Services Team implemented member
interventions for all incentive measures and several NCQA
accreditation measures:
 Outreach efforts include automated calls, mailings and
home visits to members.
 For select measures such as ADHD and diabetes measures,
the call center staff make appointments for members and
ensures transportation to their appointment.
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Anthem
 Member focused strategies:
 Data driven member interventions will be implemented using
real time HEDIS reports.
 Implemented incentives for timely prenatal and postpartum
visits.
 Developing marketing strategies to promote preventive
visits/medical home
 Working with Indiana WIC to design the cover sleeve for the
WIC checks to include information about the importance of
preventive visits and keeping member’s contact information
current with the State (so we can find our members).
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Anthem
 Member focused strategies:
 CRC ER initiative capturing members seen in the ER with
follow up phone calls and education toward true ER
 Member focus toward promoting “Medical Home” and
importance of annual well care visits with unlimited
transportation services to get members to those
appointments
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Anthem
 Data focused strategies:
 Accurate and periodic monitoring of HEDIS performance of
Anthem, network physicians, and physician groups through
ManagedCare.com.
 Develop reports of members with gaps in care to assist with
member and provider interventions.
 Evaluate the effectiveness of member and physician
interventions to identify best practices.
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Anthem
 Healthy Habits Count for You and Your Baby – Prenatal
Program – Anthem
 The Healthy Habits Count for You and Your Baby Program,
hereafter referred to as the “prenatal program”, provides
members with a comprehensive program of prenatal and
postpartum care. The program is designed to identify
members who are pregnant, encourage early and on-going
prenatal and postpartum care and provide case
management for members with high-risk pregnancies while
increasing members’ access to prenatal care.
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Anthem
 Healthy Habits Count for You and Your Baby – Prenatal Program –
Anthem
 Key components:
 Prenatal member education booklet
 Case management when appropriate
 Access to free prenatal care (first 30 weeks of gestation) and related
health education
 Gifts for timely prenatal and postpartum care
 Referrals for social services including crib program
 Breastfeeding support line
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Anthem
 Healthy Habits Count for You with Asthma – Asthma Education – Anthem
 Analysis of Anthem claims prevalence report reveals that asthma
ranks among the top diagnoses. Given the high rate of members
with asthma, the Anthem Healthy Habits Count with Asthma
(“HHCA”) program is designed as a multifaceted program
encompassing health education, member outreach, case
management and physician clinical support.
 Anthem collaborates with plan physicians and pharmacies to
promote the diagnosis, treatment and management of asthma
according to the most current asthma clinical practice guidelines
set forth by the National Heart, Lung, and Blood Institute (NHLBI).
The HHCA member and provider interventions were developed in
accordance with the NHLBI asthma recommendations for asthma
treatment and management.
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Anthem
 Key components:
 Member stratification into 3 risk levels – low, medium & high based
on hospitalization and use of quick relief meds
 Condition monitoring
 Patient adherence
 Consideration of other health conditions
 Lifestyle issues
 Asthma member education booklet which includes asthma action
plan and peak flow meter monitoring
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Anthem
 Childhood Obesity Program – Office Toolkit for Providers
 In response to the increasing prevalence of childhood
obesity, Anthem is facilitating standard screening for obesity
and encouraging children and their families to eat healthy
and be physically active. The 2009 Childhood Obesity
Office Toolkit is designed to support a physician’s office in
providing care around healthy weight, nutrition, and
physical activity.
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Anthem
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Childhood Obesity Program – Office Toolkit for Providers
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Key components in the toolkit include:
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Get Up and Get Moving Family Activity Book
Body Mass Index (BMI) brochure for parents
AAFP Childhood Obesity CME Bulletin
Online BMI training for clinical staff
Anthem Blue Cross and Blue Shield BMI wheel
CDC BMI growth chart for age and sex
Provider’s Family Counseling Guide to address childhood obesity
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Managed Health Services - HEDIS
Initiatives
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OMPP & NCQA Focused Performance Measures
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Educational Material – MHS has developed and issued education material such as
HEDIS Quick Reference Guide and Healthwatch (EPSDT) chart tool
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Provider Education Session – HEDIS Education sessions offered throughout The State to
assist our provider network in education regarding what is needed to achieve goals .
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Scorecard Mailing - Quarterly scorecard information to PMP network. Provides a
snapshot of current metrics and listing of members identified as not receiving service
to date and aid in patient outreach
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Billing/Claims assistance – MHS team providing one on one education sessions with
office to provide instruction on appropriate EPSDT and HEDIS billing procedures.
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Member Outreach – Outreach calls and mailings issued to members identified as in
need of services. Connections team available to assist provider with member
contact.
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Managed Health Services - HEDIS
Initiatives
 Preventative Health Action Committee – Multi departmental workgroup
set up to identify and develop clinical quality improvement activities
encompassing HEDIS and Benchmark measures for appropriate delivery
and management of healthcare interventions. Current initiatives
include:
 Smoking Cessation Intervention
 Chlamydia Screen
 Quarterly Health Initiative Focus (Women, Children,
Respiratory and Diabetic Health)
 Educational Update/Material
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Managed Health Services - HEDIS
Initiatives
 Member Outreach Programs
 Connections – Takes the plan to the member to promote
preventative health
 Birthday Postcards – Postcards sent to members in need
of well services two months before their birthday
 Preventative Reminder Calls – Outreach calls to members
in need of select preventative service reminding
importance
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Managed Health Services - HEDIS
Initiatives
 Coordinated Care Programs
 Start Smart For Your Baby
 Asthma
 Diabetes
 Lead
 Emergency Department Diversion
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Managed Health Services - HEDIS
Initiatives
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Health Check Health Day – MHS coordinated outreach event. MHS will do for
you:
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Encourages specialty type screenings for age-, gender- and
disease state-specific members.
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Create and mail letter of invitation to targeted members.
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Call members to schedule appointment, arrange transportation
and provide follow-up reminder calls.
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Provide specific billing details to ensure screening credit is
received.
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Complete a scheduling form (dictated by you) and send (via fax)
updates as new/changed/ canceled appointments arise
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Have a team on site to promote health messages, provide healthrelated giveaways and answer questions about MHS
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Managed Health Services - HEDIS
Initiatives
Health Incentive Program
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CentAccount™ Healthy Rewards
program gives members a monetary
incentive through a flexible spending
account for completing annual well
visits and health screenings.
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CentAccount MasterCard accepted
at participating groceries and
pharmacies, and is restricted to the
purchase of health-related items,
such as over-the-counter medicine.
Can also be used at
www.diapers.com to purchase items
such as diapers and bottles,
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MDwise – HEDIS
 MDwise developed a Network Improvement Program
(NIP) Team to focus on the following:
 OMPP Key Performance Measures.
 Analyze provider data and work on opportunities
for improvement in the provider community.
 Work with the Quality Improvement Team to review
medical records.
 Work with Provider Relations to conduct seminars
and training opportunities.
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MDwise - HEDIS
 MDwise will provide the following to provider offices:
 Group Comparison reports for providers produced
from data out of ManagedCare.com
 Opportunity Reports
 Educational Tools
 Updates on the Web site
 2009 Key HEDIS Measures Poster
 Well – Child First Campaign/Mini Poster
 Utilization Reports
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MDwise - HEDIS
 The Network Improvement Program (NIP) Team will be
conducting provider onsite visits to discuss HEDIS and
Key Performance measures in short training sessions.
 Training Session can consist of the following:
 Reports
 Educational Tools
 Forms and Documentation Guidelines
 Best Practices
 Provider Resources
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MDwise Educational Opportunities
 To ensure quality of care is provided to MDwise
Hoosier Healthwise members.
 Assist Providers in gaining knowledge in the following:
 HEDIS measures and requirements
 Components of each measure
 Forms and tools
 Opportunities for improvement
 Meet performance measure standards for the
State and NCQA
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MDwise Member Outreach
 Newborn letters with well – child visit schedule.
 Newborn list to each Delivery System.
 NURSE on – call post card that focuses on well – child
care and women’s screenings including
mammograms .
 Member eligible lists to PMP’s at each Delivery System.
 Education and weekly report of members with new
ADHD scripts to PMP’s.
 Outreach calls to parents of members with new ADHD
scripts to schedule a follow up appointment within 30
days.
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MDwise Member Outreach
 Case Management follow up and education on the
need for follow up after Hospitalization for Mental
Illness.
 Education on the LDL measure to members and
providers.
 Member and Provider Newsletters.
 ProviderLink (provider newsletter)
 Steps to Wellness (member newsletter)
 BLUEBELLEbeginnings program for Pregnant members.
 Member Services provides outreach calls to schedule
post partum visits with members.
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MDwise Programs
 NURSEon-call: Speak with a nurse 24 hours a day.
 RIDEwise: MDwise members get free rides to and
from doctor visits.
 WEIGHTwise: Offers support to members who want
to lose, gain, or stay at a healthy weight.
 TEENconnect: Helps pre – teens and teenagers get
more involved in their health care.
 WELLNESSchats: These are educational events. They
take place in your community and are hosted by
MDwise.
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MDwise Programs
 HELPlink: Work with a member advocate who
knows about health, school, and community
services.
 SMOKE-free: Get help kicking the tobacco
habit.
 MS.BLUEBELLE’S club for kids: Our kids club
offers special activities and mailings that
teach kids to make healthy choices.
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MDwise Programs
 BLUEBELLEbeginnings: MDwise wants to improve
birth outcomes. MDwise pregnant Members can
call to join the program. MDwise representatives
conduct a prenatal assessment and help the
mom pick a doctor for her baby. It is very
important for Hoosier Healthwise members to pick
a doctor for their baby BEFORE the baby is born.
MDwise will send out important information to the
member about the pregnancy, being a parent,
and a free gift for the baby.
 INcontrol: This program provides information and
education about chronic illness. Members learn
to manage asthma, diabetes, or other chronic
illness.
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Well – Child First
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2009 Key HEDIS Measures
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HEDIS Questions and Answers
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Drawing
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