Getting to know HEDIS

Have you ever received a HEDIS request for medical records from any insurance carrier? If so, you have already participated in quality measurement and improvement program. Mere participation gives you nothing except for satisfaction. Please keep reading to find out how to incentivize your performance.

HEDIS stands for Healthcare Effectiveness Data and Information Set. It is a set of standardized key performance indicators for healthcare providers, determined by the National Committee for Quality Assurance. HEDIS is used by healthcare providers and benefit plans alike to measure the quality of care.

If you are a healthcare provider, compliance with HEDIS and a good performance score should be in your best interests since not only does it measure your practice’s preventive care methods, but it also provides a basis for getting incentives from insurance payers. There are two methods for calculating HEDIS® rates: administrative data and hybrid data. The health plan’s claim or encounter data constitutes administrative data. Administrative data with a sample of medical record data make up hybrid data. In order to extract data for services provided but not reported to the health plan through claims/encounter data, hybrid data analysis necessitates reviewing a random sample of member medical records. Medical record review is less necessary when a claim and encounter data are accurate and timely. Services that are not appropriately billed or that are not billed at all are not included in the computation.In 2022, the National Committee for Quality Assurance (NCQA) implemented its Electronic Clinical Data Systems (ECDS) HEDIS reporting methodology to ensure that patients are provided top-quality service. The following measures can be audited this year: