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Claims Management News

Health Payer Solutions for Improving HEDIS Quality Scores

Providers will need to strengthen their medical record documentation in order to raise HEDIS quality scores.

By Vera Gruessner

Payers and providers transitioning to value-based care reimbursement need to commit to meeting and improving their HEDIS quality scores. However, the documentation involved in reporting HEDIS quality scores tends to become complex. Johns Hopkins Medicine released information detailing some of the obstacles that providers may face when reporting HEDIS quality scores to their health insurers.

Value-Based Care Reimbursement

For example, one potential problem is when patients are assigned to an incorrect primary care provider or medical records are never transferred to a new primary care physician. Sometimes payers may see medical claims with the wrong ICD-10 codes while patients may not have been continuously enrolled in their health plans.

Other times providers may make a mistake in documenting healthcare services in an electronic medical record. Finally, the requirements of certain HEDIS quality scores may not have been met.

However, there are particular steps that payers and providers can work on to improve the reporting of HEDIS quality scores, according to Johns Hopkins Medicine. First, it is necessary to have complete and accurate documentation within an electronic medical record.

Every patient visit will need to include information like the reason for the visit, relevant medical history, diagnostic results, and patient symptoms. The medical record will also need to include a diagnosis or assessment as well as a plan for future medical care.

READ MORE: Key Challenges and Solutions of Healthcare Payment Reform

With more payers moving into value-based care payment models, improving HEDIS quality scores will be an important goal for the coming years. Along with stronger medical documentation, payers could boost patient and provider engagement along with medical data sharing to improve their HEDIS scores.

In a prior interview, Dr. Thomas Mackey, PhD., a Nurse Practitioner from the University of Texas Health Services, told that electronic medical records are driving physician behavior as well as an upward tick in improved HEDIS quality scores.

“[Providers need to] have HEDIS measures all adequately listed in their electronic medical record. When a physician hasn’t met a particular HEDIS measure, it turns up in red,” Mackey said. “Doctors need to make sure that the EMR health maintenance templates are up to date with the current HEDIS measures. The EMR is so important  because they drive provider behavior.”

“If I see I need to make a checkmark or something is in red on the screen, it is a reminder and I don’t want red after my name in a patient’s record. I want to make sure I check those things off, so the EMR is driving my behavior to do something positive and to meet measures,” he added.

Some major health insurance companies have gone forward with transitioning to value-based care payment platforms, which has required a greater focus on HEDIS quality measures. For example, Humana released results last month showing that its value-based care model has boosted HEDIS quality scores by 19 percent when compared to its traditional fee-for-service Medicare Advantage plans.

READ MORE: How Payers Could Assist Primary Care Docs with Value-Based Care

This past summer, Humana also announced that it would be working with Mount Sinai Health Partners through a value-based care reimbursement arrangement in which providers would be more in charge of meeting HEDIS quality measures. Through this partnership, Humana is seeking to ensure that a minimum of 75 percent of their Medicare Advantage members are able to be treated through a value-based care platform by 2017.

A subsidiary of WellCare Health Plans called WellCare of New York has also positioned itself well in the value-based care space with six new alternative payment contracts signed this past summer. Providers working with WellCare of New York will be financially incentivized to raise their HEDIS quality scores.

With a stronger focus on HEDIS measures, providers will be able to make significant progress in quality improvement goals such as preventive health screening and greater patient satisfaction. Through financial incentives and pay-for-performance contracts, payers can incentivize providers through financial means to improve HEDIS quality scores and boost patient outcomes.

Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island, also discussed with in a prior interview the steps she took to raise HEDIS scores at Blue Cross. The outcomes of her work revolve around closing gaps in care and improving population health management.

“First, I wanted to create a very substantial pay-for-performance program where our providers are our partners in closing gaps in care,” Mamo said. “It’s all about closing gaps in care for HEDIS. So we put in place a very robust pay-for-performance program in the millions of dollars that we rolled out to our providers.”

READ MORE: Anthem Cut ER Costs by 3% with Value-Based Care Reimbursement

“It has a subset of measures in each product line where they could earn substantial amount of money by closing gaps in care. The second thing we did was work with MedeAnalytics, a cloud-based analytics platform, to build a population health registry. We started to create this population health registry, which is named Blue Insights,” she explained.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How to Overcome the Challenges of Bundled Payment Models


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