ACCREDITATION ISSUES INCLUDING HEDIS/NCQA – Class 6

Why HMO Medical Director Might Be Involved with Health Plan Employer Data and Information Set (“HEDIS”):

  • National Committee for Quality Assurance (“(NCQA”) creates HEDIS and Medical Director Might be involved in HMO’s Accreditation by NCQA
  • Medical Director Might be involved in HEDIS to help HMO try to prove quality
  • HMO medical directors might be involved in making reports for employer groups using HEDIS methodology

A way in which HMOs might try to prove quality is by using Health Plan Employer Data and Information Set (“HEDIS”). National Committee for Quality Assurance (“(NCQA”) creates HEDIS. HMO medical directors might be involved in making reports for employer groups using the HEDIS methodology and the medical director might be involved in HMO’s accreditation by NCQA.

Consider how HEDIS effects physicians. HEDIS collects information by: (1) claims based data and (2) by chart audit. For claims based data physicians need to report accurate diagnostic and procedure codes. There is about a forty percent (40%) error rate on these submissions. The only true measure is to use chart audit combined with claims based information, called hybrid method – this offers best opportunity to learn about physician performance if employer groups demand data on HEDIS format. Claims as part of data does not work with capitation because there are no claims so HMO may use audit. Calculations based on eligibility and not usage skews numbers, because the numerator changes which means the system will need someone to check checkers. From some HMO’s perspective: it is so difficult to comply with the HEDIS requirements that half of the premium goes to measuring HEDIS and one day will have to reassess what is going on. In addition, encounter form do not work effectively because must give physicians incentives to have information delivered, including credentialing.

Some HMOs are withdrawing from the HEDIS approach as they are finding it too time-consuming and costly to provide the requested information with little benefit in return.

Medical Groups and other Providers are looking at the Accreditation approach through various Accrediting Agencies as a Method of Distinguishing Themselves from Competitors – Consider: Who is Accrediting the Accreditors?

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