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Dotting the Is & Crossing the Ts: Documenting for Quality Incentives

Date: 04/16/18

As a health plan, we are focused on partnering with providers to ensure the delivery of quality-driven care to our members – your patients. That’s why HEDIS is so important to us as a health plan, and to you as a provider.

HEDIS helps providers like you effectively monitor care, prevent complications, and identify potential issues related to non-compliance. And it supports our members – your patients – in making informed decisions about their care.

Each year, during HEDIS Season, we request medical records to track specific, key HEDIS measures. Here are the measures we’re monitoring in 2018:

Well Child, 3-6 Years (Incentivized Measure)

This measure applies to members ages 3, 4, 5, and 6 who had at least one comprehensive well child visit in the measurement year. This visit must include a health and developmental history, a physical exam, and health education/anticipatory guidance.

Tips To Meet The Measure:

Use our secure provider portal to check care gap reports to identify patients in need of this visit, and schedule them.
Remember: This visit can be combined with a sick-care exam as long as all three required components are documented in the medical record.

Adolescent Well Care (Incentivized Measure)

This measure applies to members ages 12-21 with at least one comprehensive well care visit with a PCP or a OB/GYN in the measurement year. This visit must include a health and developmental history, a physical exam, and health education/anticipatory guidance.

Tips To Meet The Measure:

Use our secure provider portal to check care gap reports to identify patients in need of this visit, and schedule them.
Remember: This visit can be combined with a sick-care exam as long as all three required components are documented in the medical record.

Comprehensive Diabetes Care (Incentivized Measure)

This measure applies to members ages 18-75 with diabetes who had each of the following at least once in the measurement year: HbA1C testing, medical attention for nephropathy, retinal eye exam and blood pressure monitoring at each visit.

Tips To Meet The Measure:

Document HbA1C exams annually or more often as needed.
Document a current medication list indicating the member is on an ACE/ARB medication such as is appropriate for nephropathy attention.
Refer the member to an optometrist for an annual dilated retinal exam.

Chlamydia Screening in Women (Incentivized Measure)

This measure applies to women ages 16-24 who are identified as sexually active who received a chlamydia screening in the measurement year.

Tips To Meet The Measure:

The member’s medical record should include the date and place of the most recent screening.
Make discussion of this screening a standard part of any discussion with the member at every visit.
Explain to the member that a pelvic exam is not required to make the diagnosis. The diagnosis can be made via a urine sample screening.
Remind the member that they, too, earn an incentive for completing this screening.

Adult Access To Ambulatory Care (Incentivized Measure)

This measure applies to members ages 20+ who had an ambulatory or preventive care visit during the measurement year. The visit must include a physical exam and health education and/or anticipatory guidance.

Tips To Meet The Measure:

Use our secure provider portal to access care gap reports to identify patients in need of preventive services, and schedule the member for these services.
Document the results of the physical exam, preventive services performed, and anticipatory guidance provided in the visit.

Initiation of Injectable Progesterone [17P] (Incentivized Measure)

This measure applies to women ages 15-45 with evidence of a previous pre-term singleton birth who received one or more Progesterone injections between the 16^th and 21^st weeks of gestation.

Tips To Meet The Measure:

Review the patient’s history to determine if the patient’s previous pregnancy termed before 37 weeks.
Explain to the patient that Progesterone can increase the chances of a full-term pregnancy.

Postpartum Visit (Incentivized Measure)

This measure applies to women who had a postpartum visit on or between the 21^st and 56^th day after delivery. The visit must include notation of the visit type, and at least one of the following: pelvic exam OR Pap test OR breast exam (breastfeeding), abdominal exam, blood pressure AND weight.

Tips To Meet The Measure:

Provide continuous education to the patient throughout the pregnancy about the importance of prenatal care.
Schedule the patient’s prenatal visit prior to release from the birthing facility.
Remind the patient that they, too, receive an incentive for completing this visit.

Ambulatory Care – ED Visits (Incentivized Measure)

This measure summarizes the utilization of ambulatory care ED visits per 1,000 member months.

Tips To Meet The Measure:

Review the ED utilization reports in our secure provider portal to identify members who have presented in the ED and conduct direct outreach to schedule follow-up care.
Provide education to the member about appropriate ED use.
Refer the member to our Care Management program for assistance in guiding the member to the right care in the right place.

Want to learn more?

Reach out to your dedicated provider consultant for additional information about incentives and support programs to improve in these key quality measures. Be sure to also read these articles on our blog to learn more our incentive and quality programs and to find more tips to meet the measures: