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HEDIS OVERVIEW
PRESENTATION
August 11, 2014
PRESENTED BY: CARINA YAPYUCO, RN
HANIA ALHINNAWI , RN
RACHEL GRAY, RN
CLARICE MAYO, LVN
Agenda
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Fundamentals of HEDIS
Auto-assignment
Medicare STAR program
HEDIS medical record abstraction
Medical record review validation
Off-season supplemental data collection
Quality improvement interventions
1
What is HEDIS?
Healthcare
Effectiveness
Data and
Information
Set
HEDIS Overview Presentation—August 11, 2014
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What is HEDIS?
Most widely used set of standardized performance
measures in the managed care industry
Developed by the National Committee for Quality
Assurance (NCQA) - HEDIS was introduced in 1993
Encourages accountability and quality improvement in
health care
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Why is HEDIS important?
 Measures quality performance and identifies
areas in need of quality improvement
 Triple Aim Initiatives
 Cost Containment
 Ranking among health plans and states
 Auto-assignment
 Medicare Stars Program
 NCQA accreditation
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Who decides on HEDIS?
HEDIS measures are developed by:
 NCQA Board of Directors
 Committee on Performance Measurement (CPM)
- oversees entire measure development process
 Measurement Advisory Panels (MAPs)
- condition specific, clinical experts
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HEDIS 2014: 80 measures across 5 domains of care
 Effectiveness of Care
- Are we providing adequate, effective prevention, screening & care?
 Access/Availability of Care
- Are we meeting members’ needs? How accessible is care?
 Experience of Care (CAHPS)
- Survey captures members’ overall experience & satisfaction
 Utilization and Relative Resource Use
- Use of Services; Cost of Care for chronic diseases
 Health Plan/MCO Descriptive Information
- How do factors such as LAC’s organizational structure & management
contribute to our ability to provide quality care to our members?
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HEDIS Data Reporting
 Measurement Year (MY)
- data reflect delivery of service during the calendar year,
e.g., from 01/01/13 to 12/31/13
 Reporting Year (RY)
- data reported to NCQA in June of the year following MY
 HEDIS 2014 (RY) = 2013 data (MY)
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HEDIS Data Collection
Three data collection methods:
 Administrative
- claims, encounter, Rx, Labs
- BCS, PCR, OMW, ASM, AAB, MPM, ART, LBP
 Hybrid
- administrative & medical record data
- W34, PPC, CCS, CBP, CDC, COL, COA, MRP
 Surveys
- CAHPS, HOS
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Auto-Assignment
 Incentive employed by the states to
promote quality improvement
 Based on high quality scores, administrative
performance, access to care, financial
health and stability
 Medicaid beneficiaries are assigned
automatically to the best MCO when they
fail to choose their own health plan
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Auto-Assignment Measures for HEDIS 2014
Childhood Immunization Status (CIS)
Children who received these vaccines by their 2nd birthday:
4 DTaP + 3 IPV + 1 MMR + 3 HiB + 3 HepB + 1 VZV + 4 PCV
Well Child Visits 3rd, 4th, 5th, and 6th years (W34)
Children who had well-child visits with a PCP in MY
Cervical Cancer Screening (CCS)
Pap smear during MY or 2 years prior to MY (age 21-64), OR
Pap + HPV during MY or 4 years prior to MY (age 30-64)
Prenatal & Postpartum Care (PPC)
Prenatal care in the 1st trimester
Comprehensive Diabetes Care (CDC)
HbA1c screening in MY; LDL-C control in MY
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Medicare STAR Program
Background
STAR Ratings Strategy
1. Better Care
2. Healthier People/Healthier Communities
3. Lower Cost Through Improvements
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Star Ratings Structure
Outcomes
Intermediate Outcomes
Patient Experience
Access
Process
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Star Ratings
Excellent
Above Average
Average
Below Average
Poor
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Star Measures
Colorectal Cancer Screening (COL)
Controlling High Blood Pressure (CBP)
Care of Older Adults (COA)
 Medication Review
 Functional Status Assessment
 Pain Assessment
Comprehensive Diabetes Care (CDC)
 Eye Exam
 Nephropathy (Kidney Disease
Monitoring)
 Blood Sugar Controlled
 LDL <100 (Cholesterol Controlled)
Adult BMI Assessment (ABA)
Cholesterol Management for Patients with
Cardiovascular Conditions (CMC)
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HEDIS Star Rates
6
5
4
3
2
1
0
HEDIS 2013
HEDIS 2012
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HEDIS 2014 Medicare
Highlights for L.A. Care
5 STAR MEASURES (4)
 CMC – Cholesterol Screening
 COL – Colorectal Cancer
Screening
 ABA – Adult BMI
 CDC – Nephropathy
3 STAR MEASURES (4)
 CDC – Poor Control >9%
 CDC – LDL <100
 COA – Functional Status
4 STAR MEASURES (5)
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CBP – Controlling Blood Pressure
CDC – Eye Exam
CDC – LDL Screening
COA – Medication Review
COA – Pain Assessment
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HEDIS Timeline
 January 15—Off-season chart review ends
 January 26—HEDIS abstraction training for internal
and external Abstractor Nurses
 February 21—Abstraction begins
 March 3 & 4 — Audit Day
 April 4— Refresh of all data
 May 15—All abstraction ends
 May 17— Auditor selects 16 records from each of 5
Groups in addition to all MRR exclusions
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HEDIS Timeline
May 24—All selected records are submitted for
validation by auditors
May 29—Auditor completes Medical Record
Review Validation (MRRV)
June 8—IDSS completed and locked
July 1—Off-season medical record collection
begins
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Medical Record Retrieval: L.A. Care
Scheduler faxes out medical
records request via Verisk.
Scheduler will print all MR’s
received via their Right-Fax
system and place the records
in the alphabetically marked
bins.
NO
Scheduler will do the
following:
1. Retrieve MR placed into
their assigned bins.
2. Log receipt of MR in
Verisk and Access
Database
3. Write CIN # on MR
document.
4. Pull member folder from
file room.
5. Forward folder to Data
Entry Associate for
Scanning.
The Data Entry Associate will
then do the following:
1. Scan MR
2. Forward to Supervisor for
QC and Productivity check
Once this process is complete
the Data Entry Associate will
walk the charts over to the
assigned Nurse Abstractor.
If “No” medical records have
been received 3 days from the
initial fax out date Scheduler
will call provider’s office to
follow-up and refax request if
necessary.
Assigned Nurse will review
chart for medical record
completeness.
Yes
Nurse Abstractor will
abstract the chart via
Verisk.
Once the abstraction has
been completed the chart
will then be given to the
Over-reader.
NO
No
Provider offices that fail
to comply will be
forwarded to compliance.
Nurse Abstractor will comment
directly into Verisk in ‘Comment
Field’ as needed. Then forward the
chart back to assigned Scheduler for
further pursuit.
Charts will then be filed into medical
records room by the Data Entry
Associate .
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Medical Record Retrieval: Plan Partner
BCSC and CFST submit abstracted charts with shipment checklist to over-reader at
LAC
Health Information Data
Associate will inform overreader of missing charts
No
Health Information Data Associate ensures
that all the charts listed on the log sheet
supplied by the Plan Partner is received.
Over-reader designates that additional documents are needed.
Pending charts will be stored in the Lead Abstractors file cabinet marked “O/R
charts for Follow-Up”.
Yes
Over-reader will follow up with the
Plan Partner at the weekly
meetings.
Health Information Data Associate does the
following:
1. Log receipt of charts in the “Contact” field
in Verisk & Access Database.
2. Scan documents into the following
location:\\pixley\HOA.
The Scheduler will follow up with Plan Partner on
incomplete records.
No
Additional records are obtained from Plan
Partner. Health Information Data Associate
gives these records to Over-reader for the
over-read process.
Complete Record
Yes
Complete charts are over-read by
the Over-reader
Over-read charts that are deemed complete will be filed back
into the medical records room by the Health Information Data
Associate
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Over-read process during HEDIS
 L.A. Care over-reads 100% of all positive records, and 30%
of all charts deemed as negative during the HEDIS season
 L.A. Care works with Verisk to develop study items within
the database to track major and minor errors for each
abstractor
 All abstractors are required to maintain an average of 95%
or greater accuracy on all measures
 Inter-rater reliability is measured during the first two weeks
of the project then on an ongoing basis to ensure accuracy
and consistency amongst abstractors, with re-education as
necessary in areas of deficiency.
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Final Medical Record Review Validation
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Supplemental Medical Record Retrieval
and Abstraction (HEDIS - Off Season)
 Supplemental medical record retrieval and abstraction activities
start in July after the HEDIS results are submitted to NCQA
 Conduct office visits by HOA/FSR staff
 Provider education
 Scanning/abstracting medical records from doctors’ offices
and entered into internal databases.
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Off-Season Medical Record Retrieval via Fax
equest
HEDIS Overview Presentation—September 3, 2013
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Off-Season Off-Site Medical Record Retrieval
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Exit Interview with Provider and Staff
Discuss overall findings of the medical record audit
Discuss percentage of compliant vs non-compliant
members in each measure
-
(# of records pulled vs # of compliant records)
Discuss Provider Feedback Report
Provide education in Gaps in Care
Discuss “HEDIS at A Glance” Tool
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Supplemental Files Processing
 Request supplemental data files from:
- PPG
- IPA
- MSO
- Plan Partners
 HO&A formats the supplemental files and submit to
vendor (Verisk). Three formats: VISIT, RX, LAB
 Technical assistance and guidance are provided to the
groups if necessary.
 LA Care receives files in August, December and March
(for lag data)
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Benefits of Off Season Activities
 Increases the administrative rates for L.A. Care resulting
in a decrease in the number records for pursuit and
abstraction during HEDIS season
 Off season activities include office visits to high volume and low
performing provider offices. This gives an opportunity to provide
feedback to doctors/office staff regarding documentation, coding,
reinforcement of preventive health guidelines, education on gaps
in care, etc
 More completeness in administrative data collection to avoid the
data loss in the normal data transmission process (PCP  IPA
DDD (MSO)  Plan Partners  L.A. Care Health Plan 
Verisk)
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HO&A 2014 Interventions
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Questions?
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