Management Committee, Credentialing Committee, Performance Improvement Committee and/or other committees involved in the quality program). This review of provider specific performance data may include, but is not limited to: Site evaluation results including medical record audit, appointment availability, after-hours access, cultural proficiency, and in-office waiting time. Preventive care, including wellness exams, immunizations, prenatal care, lead screening, cervical cancer screening, breast cancer screening, and other age appropriate screenings for detection of chronic diseases or conditions. Participant complaint and grievance data. Utilization management data including emergency room visits/1000 and bed days/1000 reports. LTSS and service coordination data.
108 • • • Critical Incident reporting, sentinel events and adverse outcomes. Compliance with clinical practice guidelines. Pharmacy data including use of generics or specific drugs. Healthcare Effectiveness Data and Information Set (HEDIS) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA), which allows comparison across Health Plans. HEDIS gives purchasers and consumers the ability to distinguish between Health Plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required part of NCQA Health Plan Accreditation and the Pennsylvania Department of Health contract. As both the Pennsylvania and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the Health Plan, but to the individual provider. Pennsylvania purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a Health Insurance Company’s ability to demonstrate an improvement in preventive health outreach to its participants. Physician specific scores are being used as evidence of preventive care from primary care office practices. The rates then serve as a basis for physician incentive programs, such as “Pay for Performance.” These programs pay providers an increased premium based on scoring of such quality indicators used in HEDIS. How are HEDIS rates calculated? HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim and encounter data submitted to the Health Plan. Measures calculated using administrative data may include: annual mammogram, annual chlamydia screening, appropriate treatment of asthma, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of Participant medical records to abstract data for services rendered that were not reported to the Health Plan through claims/encounter data. Accurate and timely claim/encounter data and submission of appropriate procedure and diagnosis codes can reduce the
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