Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

4 Key Ways Payers Could Reach HEDIS Score Thresholds

To meet the requirements under HEDIS scores and quality metrics, payers should invest in pay-for-performance contracts and integrate health IT systems.

By Vera Gruessner

Health payers looking to increase consumer satisfaction and member retention may need to reach care quality metrics and HEDIS measures. The National Committee for Quality Assurance (NCQA) is responsible for many aspects of HEDIS measures and any changes that may come regarding HEDIS scores. As such, healthcare payers will need to adhere to new requirements the NCQA may outline annually. To maintain high HEDIS scores and quality metrics, payers will need to follow a number of steps outlined below.

Care Quality Metrics

Adopt a pay-for-performance contract

When working with your provider network, find medical facilities interested in working through a pay-for-performance approach, which will incentivize providers to improve their HEDIS scores and reach quality performance thresholds. Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island, told last May how implementing a pay-for-performance program allowed her health insurance company to improve their HEDIS scores.

“First, I wanted to create a very substantial pay-for-performance program where our providers are our partners in closing gaps in care. It’s all about closing gaps in care for HEDIS,” Mamo said. “So we put in place a very robust pay-for-performance program in the millions of dollars that we rolled out to our providers. It has a subset of measures in each product line where they could earn substantial amount of money by closing gaps in care.”

Implement health IT and analytics software

Mamo also described the importance of data analytics software in improving population health strategies, closing gaps in care, and improving HEDIS scores. Health IT tools can inform payers on which members are at high risk and need assistance in managing chronic conditions. Blue Cross Blue Shield of Rhode Island was able to close as many as 34,000 gaps in care with the use of data analytics and health IT systems.

“The second thing we did was work with MedeAnalytics, a cloud-based analytics platform, to build a population health registry,” Mamo explained. “We started to create this population health registry, which is named Blue Insights. That tool has all the clinical measures, the HEDIS measures, and all the pay-for-performance information. Every provider can go in and see the listed members who are high risk.”

“Providers can actually go in and enter data in the tool to let us know they completed a service and closed a gap in care,” she added.

Reach out to your provider network

Brian Drozdowicz, Executive Vice President of Product Management at Verisk Health, wrote about the importance of completing provider outreach in order to reach the necessary thresholds of HEDIS scores.

The patient data collected among health insurance companies can be a powerful tool when handed over to providers aiming to improve quality and close gaps in care. Communicating this information can also play a vital role in improving collaboration between providers and payers.

Create a training plan for the following year

Creating a training plan for meeting HEDIS scores and improving quality each year will help payers improve member retention and patient satisfaction. These training plans need to be updated on an annual basis based on new developments to HEDIS scores, said Drozdowicz.

This will help staff members stay on track and better understand all recent software updates and requirements of the NCQA. The last several months of the year should be used to plan and train staff members on reporting quality metrics and tracking HEDIS scores starting in January.

If payers follow the guidelines above for reaching the thresholds of clinical quality metrics and HEDIS scores, they will be able to keep patient satisfaction high and gain greater trust among their members. When gaps in care are closed and quality is improved, patients are likely to be more satisfied with their medical care.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How Medicare, Medicaid, and CHIP Guide the Health Payer Industry


Sign up for our free newsletter:

Our privacy policy

no, thanks