HEDIS 101 – Learning the Basics

HEDIS 101 – Learning the Basics

HEDIS is meant to simplify the medical industry, but it has become quite complex. There are changing performance measures, confusion as to who is responsible for what, and the issue of keeping up to date with medical record coding and claims. Here’s the lowdown on what HEDIS is, why it matters, and what even happens with the results.

What is HEDIS?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It was developed by the National Committee for Quality Assurance (NCQA) as a way to monitor the performance of the nation’s health plans. This retrospective review measures how well health plans perform on a wide variety of performance measures that are reviewed and set annually.

What happens with the results?

Health plans submit their results every year. These results are audited by auditors before the NCQA releases their final report. They are used to measure performance and identify areas for improvement for health plans and providers. This also help members view the overall performance of their providers. These results also serve as part of the NCQA Health Plan Ratings, Medicare Stars, and the State and Market Place Report cards that go out annually.

What is the provider’s role in HEDIS?

As a provider, your goal is to promote the health of your patients. To facilitate HEDIS, your staff assist is proving appropriate care, documenting all care in medical records and accurately coding all claims. By keeping information up to date and accurate, you can ensure that there will be no issues when audit season comes.

How is HEDIS data collected?

There are three ways that HEDIS data is collected. Administrative Data is obtained through claims databases of health plan representatives. Hybrid data is information that is taken from the claims database and review of medical records. Finally, Survey Data is obtained from both member and provider surveys.

What are the time frames and schedules?

Generally from January to May, you should begin collecting medical records. In June, these results are reported to the NCQA, and from July to October the NCQA begins releasing their results nationwide. It is important to stay up to date with your HEDIS tasks to ensure that you are able to provide accurate information whenever a request rolls in.

Do you need help with your HEDIS tasks?

If you are starting to fall behind on your HEDSI projects, or simply do not have the time or personnel to dedicate to the massive task, Chart Review Nurses can help! We work to connect qualified nurses with health care providers that need assistance with their HEDIS tasks. We can work on a project by project basis, or take over all of your HEDIS activities. From chart abstractions to coding and reporting, Chart Review Nurses can help get the job done. Visit Hedis Nurses or call (877) 328-2343 to learn more or get started!