HEDIS 101: What It Means For Providers

Date: 12/12/17

The Healthcare Effectiveness Data and Information Set, or HEDIS, is the measurement tool used by health plans to evaluate performance in terms of clinical quality and member satisfaction. HEDIS is administered by the National Committee for Quality Assurance (NCQA). As state and federal governments move toward a quality-driven healthcare model, HEDIS rates are becoming more and more important, not only to the health plan but to providers as well.

Each year, we request certain medical records from our providers for NCQA review. It’s critical that we receive these records so that we can make certain our HEDIS results accurately reflect the care provided to our members – your patients.

What Does This Mean For Providers?

As a provider in our network, you play a crucial role in improving the health of our members. We want to be sure that we are doing all we can to support your efforts to drive improvements in quality and outcomes. To that end, it’s important that you respond to records request in a timely manner. It’s also important that you document all the care you provide in your patients’ medical records and accurately code all claims.

How are HEDIS scores used?

State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts. Physician-specific scores are being used as evidence preventive care from primary care office practices. These rates then serve as a basis for physician profiling and incentive programs. You can learn more about the use and calculation of HEDIS scores on our website.

What About HIPPA?

We take the privacy of our members very seriously, and we appreciate that you do, too. HIPAA compliance of the highest importance to us! We want our providers to know that HEDIS data collection and release of information is permitted under HIPAA. This is because the disclosure is a part of quality improvement and assessment. Our HEDIS data collection does not require patient consent or authorization. We handle all patient information carefully with an ethical and legal focus on protecting, preserving and maintaining the highest standards of confidentiality.

When Is HEDIS?

Beginning in the first quarter of 2018, providers will be contacted with medical record requests from our quality team. These requests will include a member list identifying assigned measures and the minimum information needed. The collection and abstraction process must end on or before May 9, 2018.

Want more information?

Please refer to our comprehensive Provider Manual, where you will find in-depth information about our medical records review process. You may also talk to your dedicated Provider Consultant about HEDIS and to request provider materials, such as our HEDIS Reference Guide.