hedis 2018 client conference welcome to san antonio! · • client-only conference calls objectives...

1

HEDIS@ 2018Client Conference

Welcome to San Antonio!

HEDIS 101Carlo Teano & Jenna Morgan

Introductions

2

We Are Attest

• Largest NCQA Licensed Organization

• CHCAs since inception• Top performing & improvement

minded clients• Collaborative and Transparent• Support non-financial audits

Why HEDIS?

• Accreditation

• Medicare Stars

• State Requirement

• Exchange Mandate

• Group/Employer Contracting

• Other Reasons

Objectives

• High-level HEDIS overview

• Attest audit approach

• Tools and resources

• Audit expectations

3

What is HEDIS?

• H. E. D. I. S

• Gold standard in performance measurement

• 95 measures

• 7 domains of care

• 4 data collection methods

• Acronyms

What is HEDIS?• Stakeholders

– NCQA

– Plans

– Members

– Employer Groups

– Licensed Organizations

• Drives intiatives

• Required reporting

Objectives


• Attest audit approach • Tools and resources


4

The Attest Way

• Transparent

• Collaborative• Educational• Value Oriented

Our Audit: Phases

Pre-Onsite Onsite Post-

Onsite

Our Audit: Pre-Onsite

November-December

Kick Off Call

Roadmap

January

CAHPS & QRS Enrollee Survey Review

Benchmarking Before Sampling

February-March

SDS Review

Source Code Review

5

Kick Off Call• November-December

• Audit Logistics

• Discuss Any Major Changes

• ShareFile

• Queries

• Timeline

• HEDIS Team Participation is Key!

Timeline

• NCQA-Driven Deadlines

• Tailored During Kick Off Call

• Some Target Date Flexibility

• Added to Final Audit Report

• Tracked Within Issue Log

Issue Log

• Primary Communication Tool

• “Living Document”

• Timeline

• Core Set

• Approvals– Source code review

– Supplemental data

6

Roadmap

• R.O.A.D.M.A.P.

• 1st Major Audit Deliverable

• Information Management & Measure Reporting

• Organized by Sections

• Appendix 1

CAHPS & QRS Enrollee Survey• January

• Plan Role– Sample frame and CAHPS form

– Vendor deadline

– HOQ

• Attest Role– Sample frame review

– Approval letter with final sample

– HOQ

Benchmarking Review & Tool

• Benchmark early

• All rates reviewed

• Standardized Excel output

• Shared document

• Unveil the unknown

7

Outlier Toolbox

• Rate Research Tool

• Requires Plan Action

• Validates Rates & Populations

• Troubleshooting– High/ Low Rates

– High/ Low Eligible Populations

Outlier ToolboxMeasure Identifier

Measure Name

EP Benchmarking High/ Large Increase

EP Benchmarking Low/ Large Decrease

Rate Benchmarking High/ Large Increase

Rate Benchmarking Low/Large Decrease

ABA Adult BMI Assessment

• Confirm limited to members with visits in2015 or 2016• Confirm applied optional exclusion• Confirm anchor date is applied• Confirm all enrollment segments linked correct, applies to in-house and plans that 'normalize' enrollment data prior to loading in software• Confirm that the age criteria is correct

• Confirm that the age criteria is correct• Confirm all outpatient claims from all sources loaded• Confirm two years of visits used• Confirm all enrollment segments linked correct, applies to in-house and plans that 'normalize' enrollment data prior to loading in software

• Confirm counting members, not events• Confirm not counting height and weight recordings instead of BMI• Confirm weight requirement for hybrid is being followed• Confirm plan pays for applicable HCPCS codes • Confirm not using ranges and thresholds

• Confirm plan considering 2 years of data• Confirm not looking for only BMI on visit that qualified member for EP• Confirm reviewers aren't looking for BMI age-growth charts for >18 yr olds• Confirm excluding for pregnancy in MY and PY

SDS & Source Code Reviews• February-March

• Supplemental Data – Roadmap Section 5

– 2 types

– PSV

• Source Code– Core set

– SCR team

8

Our Audit: Onsite

• February-April

• Interviews & Demos

• Rate Review

• Collaborative:– Focus on plan needs

– You help drive the agenda!

Our Audit: Post-Onsite• May-June

• MRRV– Frozen Counts

– Sample Selection

• Issue Log Closure

• IDSS Rate Review

• Patient-Level Detail Review

• Final Audit Report

Objectives



• Tools and resources• Audit expectations

9

Tools and Resources - NCQA

• HEDIS Volumes 2 & 5

• Policy/Program Clarifications

• FAQs

• Other E-Publications

• HEDIS User Groups

• Conferences & Webinars

• IDSS

Tools and Resources - Attest

• Communications Manual

• Issue Log

• Outlier Toolbox

• World Class Audit Tools

• PCS Q&A

• Specialized Teams

• Client-Only Conference Calls

Objectives



• Tools and resources


10

Audit Expectations

• Turnaround Time

• Accountability

• Transparency

• Communicate Goals Mutually– Your team

– Attest team

Recap

• HEDIS Overview

• Attest Audit Approach

• Tools and Resources

• Season Expectations

Navigating the Workshop

• Main Sessions (Wednesday-Friday)

• Concurrent Sessions (Thursday)Option 1 HEDIS Data Aggregation & ETL

Option 2 Medical Records: 2017 Client Experience

Option 3 Medicaid Reporting Tactics

Option 4 Patient Level Detail Files

11

Enjoy the Workshop!

HEDIS@ 2018Client Conference

Welcome to San Antonio!

Welcome to San AntonioBob Oakleaf

12

Meet Our Team

On The Horizon

• More Changes

• A Bright Future

Ground Rules

Respect Others No Sidebars

Wait for Microphone

Keep an Open Mind

100% Focus

Phones/Email Off

Be Yourself &

Be Honest

Discomfort is Optional

13

Questions

Key Logistics

• Restrooms

• Food & Drink

• Special Meals –Name Badge

What’s in Store for Day 1?

• HEDIS 2018 Specification Updates

• 2018 Strategies For Success

14

Day 2 At a Glance

• Looking Beyond HEDIS 2018

• Challenging Administrative Measures

• Strategies For Medical Record Abstraction & Validation

• Supplemental Data

• Concurrent Sessions

Day 2 Concurrent Sessions• New Format!

• Select 2 of 4 Options:– HEDIS Data Aggregation & ETL

– Medical Records: 2017 Client Experience

– Medicaid Reporting Tactics

– Patient Level Detail Files

Overview of Day 3

• Benchmarking Process & Measure Trends

• PCS & FAQ Highlights

• What To Do Between Now & January 1st

15

Affinity Event

• Dave & Buster’s• Games, Food, Wine & Beer• Shops At Rivercenter• 6-9 PM, Wed Oct 11th

Inovalon

HEDIS 2018 Specifications UpdateMelissa Sheesley

16

Agenda

• General Guidelines Changes

• Measure Changes

• New Measures

General Guideline Changes

GG 9 – Timeline– Preliminary Rates submitted by April 13

– May 9 – MRR Abstraction completed and counts submitted

– May 15 – Records sent to auditor

– June 1 – Plan locked IDSS

General Guideline Changes

• Clarified GG 10, Deleted GG 32

• GG 33 Home visits (TU)

• Clarified GG 34 codes in medical record

• GG 45 same claim

17

Guidelines for Sampling

• Minimum Required Sample Size (MRSS) is required

• Final Sample Size (FSS) no longer allowed

Effectiveness of Care

Pregnancy exclusion

only allowed if Female*

*Added to all applicable measures


• WCC – “appetite” ≠ Nutrition counseling

• IMA – added 2-dose HPV

• BCS & COL– Required Exclusions

• BCS: Digital Breast Tomosynthesis

18


• COA – Several minor clarifications

• CWP/URI – Revised episode date

• Clarification about ED or Observation visit IP Stay


• CDC – minor changes

• “Direct transfer”

• Changed populations – (MMA, AMR, CBP, OMW)

• Added telehealth (MH/CD)

Access/Availability of Care

• ADV – Removed value sets

• IET – Rx benefit, other changes

• PPC – Decision Rule 3

19

Utilization and RA Utilization

• IAD/ MPT – breakdown

• HAI – clarifications

• PCR – Added MCD

Acute Hospital Utilization (formerly IPU)

• Added Observation Stay Discharges

• Outlier vs. Non-Outlier

• PPD and PUCD

• New Data Elements

Hospitalization for Potentially Preventable Complications

• Added observation stays

• Chronic/Acute ACSC outlier/non-outlier

• Exclusion – members in long-term institutional settings

20

Retired Measures (TU)

Frequency of Ongoing Prenatal Care

MPM : Removed Digoxin (all LOB)

QRS Changes

• Measures reported unchanged

• Slight tweaks to questions

– Access to care

– Added “In last 6 months,”

Publicly Reported

• Follow-up after ED for MH (FUM)

• Follow-up after ED for AOD (FUA)

• Standardized Healthcare-Associated Infection Ratio (HAI)

• Depression Readmission (DRR)

21

New Measures

• Transitions of Care (TRC)

• Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions(FMC)

• Use of Opioids at High Dosage (UOD)

• Use of Opioids from Multiple Providers (UOP)

New Measures

• Depression Screening and Follow-Up for Adolescents and Adults (DSF)

• Unhealthy Alcohol Use Screening and Follow-Up (ASF)

• Pneumococcal Vaccination Coverage for Older Adults (PVC)

Transitions of CareEligible Pop Notification of

Inpatient Admission

Receipt of Discharge

Information

Patient Engagement

After InpatientDischarge

Medication Reconciliation Post-Discharge

18+ years oldCE = Date of

Discharge + 30 days (Acute or

Non-Acute)

Hybrid only Hybrid only Admin + hybrid Admin + hybrid

1 medical record Communication in PCP Chart

Communication in PCP Chart

Follow-up visit (office, home, tele

or transitional)

Same as MRP

22

Follow-up after ED Visit for People w/ Chronic Conditions

Denominator Numerator

Age 18+CE: 365 days prior to ED visit through 7 days after

Follow-up within 7 days after the ED visit

ED visit between 1/1 and 12/24Include all visits but limit to only the first one within an 8 day period

Include visits that occur on same day as ED visit

Dx: 2 or more chronic conditions in MY or PY (before ED visit)

OP, BH, Telephone, Transitional Care, Case Mgmt, Complex Care Mgmt

Use of Opioids at High Dosage

• Lower rate = better

• COM, MCD, MCR

• Age 18+

• Medical and Rx Benefit

• Numerator: Average MED >120mg MED

Use of Opioids from Multiple Providers

• Lower rate = better

• COM, MCR, MCD

• 3 rates– Prescribers

– Pharmacies

– Prescribers & Pharmacies

23

Depression Screening and Follow-up (DSF)

Initial Population Depression Screening Follow-up on Positive Screen

Age 12+CE: MY, 1 gap

Denom: Members in InitialPopulation

Denom: All members from Numerator 1 who screened positive for Depression

Exclusion: Bipolar disorder MY or PY; Depression in PY; Hospice MY

Num: Members screened for clinical depression using an age-appropriate standardized tool Jan 1-Dec 1 MY

Num: Follow-up care on or 30 days after positive screening

Unhealthy Alcohol Use Screening and Follow-up (ASF)

Initial Population Alcohol Screen (Rate 1) Counseling & Follow-up (Rate 2)

Age 18+ as of 11/1/PYCE: MY, 1 gap

Denom: Members in initial population

Denom: Members who were screened and had positive result – meaning unhealthy alcohol use

Exclusion: Alcohol use disorder, dementia, hospice

Num: Members who werescreened using systematic tool and had a result 1/1/MY -11/1/MY

Members who had follow-upcare on date of initial positive screen of 61days following

Pneumococcal Vaccine Coverage for Older Adults (PVC)

Denominator Numerator

Age 65+CE: MY, 1 gap

Immunocompentent: PCV13 and PPS23 at least 12 months apart*First occurrence after age 60

Exclude: Active chemo, bone marrow transplant, anaphylactic reaction, hospice

Immunocompromising: PCV13 and PPS23 at least 8 weeks apart

Members who qualify for either = Hit

24

Questions

2018 Strategies for SuccessLaura Hart

Objectives

• Challenges of HEDIS 2017

• Focus HEDIS 2018

• Tools for Success

25

Challenge Category

• Measures

• Data

• Medical Record Review

• Audit

Specification Complexity

• 2017 New Measures Impact– HAI

– FUA, FUM

• Measure Change Reality Check– Interpretation Matters

– Process Knowledge Key

In This Corner…Data

• Source Identification

• Data Clean-up / Consolidation

• Mapping

26

Record Obstacles

• Time Crunch

• Provider-Member Mismatch

• Over-read Errors

• Validation Documentation

Audit Awareness

• Supplemental Data– Increased # of sources

– Focus on QA

• Rate Reviews & Certification

• Queries

Focus on 2018

• Know What’s New

• Anticipate Similar Challenges

• Prepare the Game Plan

• Be Ready to Adjust

27

What’s Going On?

• Organization Changes– Structure

– Focus: community, goals

• Process Updates

• Vendor Management

Deep Dive into Data

• Are you being efficient?– Redundancy

– Consolidation

• Are organizational goals aligned?

Prepare for Data Demands

• Step 1: Technical Specification

• Step 2: Implementation Guide / Layout Changes

• Step 3: Warehouse Review

• Step 4: ETL Updates

28

Closer Look: Opioids

• Rx Data Elements– NPI

– Day Supply

– Quantity Dispensed

• Reversals

Closer Look: ECDS

• Voluntary Report: Highly Encouraged

• How do you flag?– ECDS Layout

– Hierarchy

• Mapping Requirements

Compressed Timeline

• Medical Record Cut-off– May 9: MRR Counts

– May 31: Corrective Action

• Plan Lock: June 1

29

Mitigate Risk

• Be Prepared– Do a Test Run

– Clean up Provider File

– Notify Providers

– Set Expectations

• Identify In-House Records

Rely On…

• Supplemental Data – Load Early

– Identify New Sources

• Auditor Communication

Query Success

• 6 Categories

• Driven by Preliminary Rates

• Refer to Outlier Toolbox

• Ask Questions

30

Onsite Query

• Auditor Selects Measure(s)

• Plan Provides Detail

• Auditor Selects Members / Events– Prior to onsite

– Prepare staff

• Review Systems Onsite

Tools for Success

• Communications Manual

• Issue Log

• Outlier Toolbox

• Vendor Reports

• Audit Team

Things to Remember…

• Team Effort

• Pace Yourself

• Utilize All Resources

31

Questions

Looking Beyond HEDIS 2018Bob Oakleaf

Looking Beyond HEDIS 2018• We tend to be mono

focused on the next HEDIS season

• We will look more broadly at health care quality

• Future of HEDIS

32

My POV on Health Care• My biases

– Everyone should have health coverage

– We should be measuring and improving health care for everyone

– Quality results available to all

What a Difference a Year Makes

• Last Year– ACA Increasing

Quality Reporting for QHPs

– Medicaid expansion in Managed Products

– MACRA/MIPS

What a Difference a Year Makes

• QHP Enrollment

• QHP STARS

• MACRA/MIPS

33

QHP Enrollment

• Effectuated QHP enrollments:– 3/2016: 10.8

million

– 3/2017: 10.3 million

QHP STARS

• ACA mandated reporting of quality

• 2017 OE was to be “go live”

• Only 2 states reported

QHP STARS

• Manitowoc, WI– 29 plan options, all

had a STARS score displayed

– 26 had 4 STARS

– 3 had 3 STARS

34

MACRA/MIPS• CMS Program to

move physicians to “Value Based” Payments.– Alternative Payment

Methods (APMs)

– Merit Based Incentive Program (MIPS)

MACRA/MIPS

• APMs = Incentive Payments/Risk Specific Conditions

• MIPS = Quality Reporting Incentive Payments

MACRA/MIPS• MIPS

– Excluded: <$30K Medicare, < 100 Medicare patients, new to Medicare = 940,000

– Included: 419,000

35

MIPS Measures

• Quality reporting– Example; Internal Medicine

• 37 potential measures, pick 6 including one outcome

• Cover at least half of Medicare members

• 15 of 37 are HEDIS

• 5 of other measures with cross over affect

• Possible reporting set:– CBP, COL, BCS, CDC

Eye, CDC HbA1C Level, OWM

MIPS Financial Incentives• Penalties for not

participating

• Bonus for submitting

• 2017 results, March 2018 submission, impacts 2019 payments

• Increase from +/- 4% to 9%

Coverage/Quality Scorecard

• Progress on Coverage: D

• Progress on Quality Reporting: C-

36

Future State of HEDIS• HEDIS Beyond 2018

– Hybrid will go away

– Faster turn over of measures

– More risk adjusted measures

– Socio-economic status reporting

Questions?

Challenging Administrative MeasuresGlen Braden

37

The horror…• Understanding and

Impacting Challenging Measures– HAI

– Risk Adjusted Measures

• PCR

• IHU (AHU), EDU, HPC

HAI Overview• All acute discharges

• Sum discharges by Hospital– Need ID to match NHSN SIR

– National Healthcare Safety Network (NHSH) calculates SIR

• Pull Scores from Table HSIR

• Weight “Scores”

• 4 infection ratios

HAI Overview (MRSA)

• Proportion of Total Discharges

ClassificationAcute

DischargesProportion

HighProportion

ModProportion

LowHospital 1 High 4 0.40Hospital 2 Moderate 2 0.20Hospital 3 Low 4 0.40

Total 10

38

HAI Example

• Unknown Proportion (added Hospital 4)

• Plan Weighted SIR

Acute Discharges

Proportion High

Proportion Mod

Proportion Low

Proportion Unknown SIR

Plan Weighted

Hospital 1 4 0.31 2.68Hospital 2 2 0.15 1.1Hospital 3 4 0.31 0.67Hospital 4 3 0.23Total 13 1.2

Final HAI Table

ClassificationTotal

Inpatient Discharges

Number of Hospitals

with Inpatient

Discharges

Number of Hosptials

with Reportable

SIR

Proportion of Total

Discharges from High SIR

Hospitals

Proportion of Total

Discharges from Moderate SIR Hospitals

Proportion of Total

Discharges from Low SIR

Hospital

Proportion of Total

Discharges from Hospitals

with Unavailable

SIR

Plan-Weighted

SIR

HAI-5 (MRSA)

10 4 3 0.31 0.15 0.31 0.23 1.2

HAI changes and what they mean to you

• Added # of Hospitals with Inpatient Discharges

• Mapping and that HSIR table– Removed “contracted”

– ALL Hospitals (really?)

39

HAI Changes• Clarified “Unavailable” Hospitals

– Required to report but do not have a reported SIR

– Are not required to report to NHSN• Critical Access, Long term Care

• Cancer Hospitals, Children’s

– Have discharges but are not listed in table HSIR

HAI Changes• Clarified “Unavailable” Hospitals

– Required to report but do not have a reported SIR

– Are not required to report to NHSN• Critical Access, Long term Care

• Cancer Hospitals, Children’s

– Have discharges but are not listed in table HSIR

Audit Considerations

• HAI is required for Medicare

• Bias is a +/- 10% change in Rate

• Use of Service GG’s

• How big is the proportion of “Unavailable”?– Not Required/ No SIR

– Or Not Mapped

40

HAI Red Flag Example

ClassificationTotal

Inpatient Discharges

Number of Hospitals

with Inpatient

Discharges

Number of Hosptials

with Reportable

SIR

Proportion of Total

Discharges from High SIR

Hospitals

Proportion of Total

Discharges from Moderate SIR Hospitals

Proportion of Total

Discharges from Low SIR

Hospital

Proportion of Total

Discharges from Hospitals

with Unavailable

SIR

Plan-Weighted

SIR

HAI-5 (MRSA)

10 4 3 0.31 0.15 0.31 0.23 1.2

HAI Take Away

1. May not need to map all Hospitals, but most of the Hospital discharge volume must be mapped

2. If UOS is ok, HAI will be too if you do #1 right

Risk Adjusted Measures• PCR - Acute IP Re-admissions vs

expected

• AHU – Acute & observation discharges vs expected– For Non-”Outliers”

• EDU – ED visits vs expected

• HPC – Acute & observation discharges vs expected for certain conditions

41

SDS Nightmares

• Huge increase in EHR feeds

• Can impact Observed Events– Discharges

• Denominator and Numerator

• Cannot impact Risk Adjustment

SDS Take Aways

• Always flag SDS records as denied– Does not impact UOS/ Risk Adjusted

– Does impact EOC

• SDS cannot impact Risk– Correct Coding

– Encounter data is not SDS

Understanding PCR Events

• Historical (wrong) Thinking– Look for first IP stay to

identify index stay

– Readmission in 30 days?

– Next Index stay

– A single can’t be an index stay and a readmission

42

Understanding PCR Events

• Correct Understanding– All acute inpatient stays are Index

Stays unless specifically excluded• Member died

• Diagnosis exclusions

• Planned stays– (Chemo, Rehab, Transplant, other

planned)

Understanding PCR Events• Readmissions (Numerator)

– An index stay within 30 days the previous index stay’s discharge date

– 4 Index stays & 1 readmit

Admit Discharge Index Stay? Readmission?Stay 1 3/4/17 3/7/17 Yes NoStay 2 6/15/17 6/27/17 Yes NoStay 3 7/2/17 7/8/17 Yes YesStay 4 9/12/17 9/13/17 Yes No

Investigation

• Take it to the member level– Pull all claims for 1 member

– Compare to counts from software• Paid/ Denied

• Exclusion criteria

• Other sources?

43

AHU (IHU)

• Benchmarking– Observed should be lower than PY

• Added Observation but

• Excluded Outliers if 3 or more stays

– Non-Outliers and Outliers Members• Rates now Observed/ Expected per 1000

Non-Outlier members

– Surg + Med = Total? Not always

HPC

• Benchmarking (Same impact?)– Lower observed than PY

• Required Exclusions– Institutional SNP members

– Living in long-term care institution• LTI Flag in Monthly Membership File

– Outliers (3 or more)

Concerns?

• Observation coding concerns• Rev Code 0760, 0762, 0769

• ED vs Obs or Admit vs Obs?

• Medicare PLD Changes are coming– Outlier / Non-Outlier for AHU/ HPC

– Clarified rounding rules for AHU/ EDU/ HPC

44

Take Aways

• Member Date of Death– Use as Enrollment termination date if

possible

– Review how your vendor identifies member death (possible area for mapping)

• Load SDS data as denied – not capitated encounters

• Correct coding on hospital claims?

• Monthly Membership File (LTI indicator)

Strategies for Medical Record Abstraction and Validation

Kelli Graziano, MD

Objectives

• 2018 Changes

• Problem Measures

• Exclusions

• Best Practices

45

Changes for 2018

• New hybrid measure

• Measure retired

• Changes to existing measures

• MRRV Timeline

Transitions of Care

• New Measure

• 4 components

• All need to come from same chart

Frequency of Prenatal Care

• Good news!

• Measure has been retired

46

Medication Reconciliation Post Discharge

• New “current medication list” requirement

• Method used to identify current meds outside scope

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

• Nutrition component

• Reference to appetite alone is no longer compliant

• What is the child eating?

Immunizations for Adolescents

• Added the option for a 2 dose HPV vaccination series

• Must be 146 days apart

47

Care for Older Adults• Continence added to

ADL options

• Cranial nerve assessment does not meet sensory component

• Speech assessment clarified

MRRV Timeline

• New deadline May 9

• Abstraction must be completed

• No exceptions

Problem Measures• Medication Reconciliation

Post Discharge (MRP)

• Controlling High Blood Pressure (CBP)

• Comprehensive Diabetes Care Eye/A1c (CDC)

• Colorectal Cancer Screening (COL)

• Prenatal and Postpartum Care (PPC)

• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

48

MRP

• Need to see evidence of a reconciliation, not just a med review

• Comparison between inpatient and outpatient medications

• Need appropriate provider type

Compliant Reconciliation

Compliant Reconciliation

49

CBP• Documentation must come

from the chart of the provider managing HTN

• Need to clarify when submitting specialist notes

• Reading and diagnosis cannot come from same date of service

• Eligible blood pressures

CBP Common Error

CDC Eye and HbA1c

• Any evidence of retinopathy is considered positive

• Needs to be a clear date of testing

50

Hypertensive Retinopathy

Hypertensive Retinopathy

HbA1C Date Error

51

COL

• Counting FIT testing as FIT DNA testing

• Testing method not specified

COL Screening Errors• FIT vs FIT DNA • Type not specified

PPC• EDD

• Delivery Date

• Need to use consistent methods to identify EDD

• Can use either at a member level

52

WCC

• Developmental assessments do not count

• Acute/chronic conditions do not count

Nutrition Counseling Errors

Physical Activity Counseling Errors

53

Exclusions• General guidance

• Comprehensive Diabetes Care

• Controlling High Blood Pressure

• Prenatal and Postpartum Care

General Guidance• Take the hit!

– Increase rates– Required vs Optional

• New mandatory exclusion for select measures

• Know the specs

Comprehensive Diabetes Care

• Require 2 years of supporting documentation– 2 years of medical

records– 2 years of claims data

• Absence of diagnosis is not sufficient for valid data error

54

Controlling High Blood Pressure

• Cannot confirm diagnosis

• Optional:– ESRD, Kidney

transplant, dialysis

– Pregnancy

– Non acute stay in MY

Prenatal and Postpartum Care

• EDD or DOD not on or between Nov 6 of PY and Nov 5 of MY

• Non-live births

Best Practices

• Submitting MRR questions

• Convenience Sample

• Record abstraction

• Record submission

55

MRR Questions• New format for

submitting MRR questions

• Standardized excel format

• Cutoff date April 13th

Convenience Sample• Exempt:

– Passed MRRV for all measures validated in prior year

– No significant process changes

• May still request one

Chart Submission • Copy of Abstract

• Copy of Chart– Highlight or Mark

– Not Entire Chart

– No Snippets

– Full Page(s), but Minimum Necessary

• Single PDF per person/measure preferred

56

Best Practices

• Records on Hand

• Review Records Prior to Submission– Hit highlighted?– Abstraction Errors?– Correct name?

• File Submission– 1 zip file per measure

Thank you!• Questions?

Lunch

Concurrent Sessions Begin at 1 pm

57

Supplemental DataCarlo Teano

BUT FIRST…CHARLIE’S 1!

OBJECTIVES• What SDS are plans

using most?

• What’s Non-Standard?– How do I pass PSV?

• What’s the word on ECDS?

58

Top 5 SDS

Top 5 SDS - #5

#5 Ancillary Data

• Lab– Nat’l & regional vendors

– Clinics, hospitals

– Leakage

• Vision– Provider specialty

• Mostly Standard

ROI = 9

59

Top 5 SDS - #4

#4 Coordinated Care

• Clinical care focus– COA

• Case management

• RNs, NPs, pharmacist, care coordinators

• Communication is key

ROI = 7

Coordinated Care Expansion• Clinical Document

Architecture– HL7 markup standard

– Allows IT processing

• Continuity of Care Document– Not complete history

– Exchange information

60

Top 5 SDS - #3

#3 Year-Round Abstraction

• More than HEDIS

• Provider office abstraction

• Target population

• Trained abstractors

• Frequent IRR

• Med records saved

ROI = 7

Top 5 SDS - #2

61

#2 Immunization Registries

• State / county level

• Criteria-based pull

• Annual request

• Standard SDS

• CIS, IMA rates up

ROI = 8

Top 5 SDS - #1

#1 EMRs• Major push to access

• First BMIs and biometrics

• Meet w/clinics w/EMRs

• If pulling from comments– Turn into code, then not

standard

– Consider SDS splitBest

Practice!

ROI = 8

62

EMR Uses

• Biometrics

• Vitals

• Immunizations

• Medication review

• Screenings

Example Standard EMR1. Plan program pulls

member from EPIC EMR

2. Direct to certified vendor

3. Send to EMR_IN file

4. Review file & data audit

5. Send SDS file to vendor

6. QA process

Example Non-Standard EMR

1. Access database to groups monthly

2. Group opportunity to provide service evidence

3. Plan receives file• Formatting & edit checks

4. Proof-of-Service checks

63

EMR Challenges• Access

• Data structure

• Systems variability

• Provider abrasion

• Member targeting

• Mapping

• Enterprise support

OBJECTIVES

• What SDS are plans using most?



Non-Standard SDS

• Capture missing service data– Not received via admin

sources, manual

• Irregular submission, unstable format

• Follow clear P&Ps

64

Non-Standard SDS Examples• EHR (uncertified eMeasure

modules)

• Provider portals

• Health info registry

• Home visit data collection

– Must show accountability

• Member-reported servicesNEW TU MY2017!

Primary Source Verification• Annual requirement

• Legal health record only

• Shows services rendered

• Pharmacy data– Name, strength, route, fill date

• Hybrid follows hybrid rulesTIP: PSV must not occur before Mar 1 unless all SDS processes are complete.

Proof of Service That Counts• Chart from provider or PCP

• Clinical visit report/ summary

– Lab, radiology

• Online EHR screen shot

– State / county immunization registry

• Minimum necessary Best Practice!

65

Proof of Service Not Allowed

• Member survey– Completed by member

– Except LDM / RDM data

• Phone calls– Recorded calls about

services rendered

OBJECTIVES• What SDS are plans using

most?



What’s an ECDS?• Member database network

– PHI, healthcare experiences

• Care-related activities– Evidence-based

– Quality management

– Outcome reporting

• Automated quality metrics

66

ECDS Domain of Care• 6th domain of care:

– Effectiveness of Care

– Access/Availability of Care

– Experience of Care

– Utilization and Risk Adjusted

– Health Plan Descriptive Info

– Measures Collected Using Electronic Clinical Data Systems

Data Collection Methods

• HEDIS data collection:– Administrative

– Hybrid

– Survey

– Electronic Clinical Data Systems (ECDS)

ECDS vs. SDS

• SDS no denominator events

• ECDS– Uses same data classified

as SDS

– Different reporting rules

– All reporting elements

67

ECDS Data Collection• Source System of Record (SSoR)

– Authoritative source for measure Quality Data Element (QDE)

– Standard & Non-Standard SDS

– Subject to GG#33 review rules• P&Ps, standard layout

• Automated load process

• Structured data elements

Source Priority

• SSoR priority categorization1. EHR

2. HIE/clinical registry

3. Case management registry

4. Administrative claims

• Assigned 1 SSoR

* TIP: Must freeze ECDS-SSoR import by March 1

ECDS Data Systems• EHR

– Real-time, patient-centered

– Medical & treatment history

• HIE/Clinical registry– State, regional HIEs

– Immunization systems

– Public health agency systems

68

ECDS Data Systems (cont’d)• Case management system

– Member assessment

– Care planning & coordination

– Any system to support disease management

• Administrative claim– Services incurred

– Paid / expects to pay

NCQA Learning Collaborative

• Collaboration– NCQA &13 plans

reported ECDS measures

• Collection– Clinical data to report on

depression measures• DMS, DRR, DSF

Plan A

• Non-profit

• Low-income members

• MCD, ACA, MA, Duals

• 1.5M members

• KY, OH, IN, WV, GA

69

Plan A - ECDS Data Sources

• Care management system– PHQ-9 data

• Registry data– Nurse case managers

• Population health management– Community-based

Plan A - Lessons Learned

• Subject matter expertise required

• Closer partnering with regional / state HIEs

• Enterprise data use knowledge needed

• Much work remains

Plan A - Best Advice to Plans

• Create a plan from your own conditions

• Structure, structure, structure

• Better communication

• Be realistic

70

Plan B

• San Juan, Puerto Rico

• MA HMO and PPO

• Government health plan

• 110k members

Plan B - ECDS Data Sources

• APS

• MBHO

• Claims

• HIE & HRA platforms

Plan B - Lessons Learned

• Provider network communication

• Need for structured data

• Operations changes required

• Adaptation is key

71

Plan B - Best Advice to Plans

• HIEs challenging and promising

• Cross-functional communication

• Strive for structure

• Verify information

NCQA Updates as a Result

• Measure element level by data source– Denominator

– Numerator

– Exclusions

• Clarifying definitions– Point of care access

ECDS Mission & Future• ECDS innovation driver

– Sharing

– Interoperability

• NCQA actively engaging– Plans

– EHR vendors

– Auditors

72

RE-CAP

• What SDS are plans using most?



QUESTIONS ?

Benchmarking Process & Measures TrendsKevin Gregory

73

Objectives

• Timeline

• Benchmarking Logistics

• HEDIS 2018 Trends

• New Measure Results

Benchmarking Milestones

Audit Step Date

Hybrid Rate Review Jan 30th

Preliminary Benchmarking Complete May 4th

Full IDSS Rate Review & PLD May 18th

IDSS Plan Lock Deadline June 1st

Rates Marked Final in IDSS June 15th

Attest Benchmarking Tool

• 3 Year Rate Trending– NCQA & Attest

– Admin & Hybrid

– EP per 1,000

• Logic Tests

• MRSS Calculations

74

Preliminary Benchmarking

• Data Submission Options– XML Upload File

– Full Excel Submission

• Supplemental Excel File– New Measures

– Modified Measures

– ENP, MRSS

• Typically Subset of Measures

IDSS Benchmarking

• XML Upload– Validations &

Calculations

• IDSS Downloads– XML Processed Rates

– Workbooks

– Tier Warnings

IDSS Lock Considerations• All Rate Review Concerns

Addressed

• IDSS Warning Messages

• PLD Must Tie

• Hybrid Frozen Counts Unchanged

• IDSS and Appendix 1 Consistency

75

Attest Feedback• Excel Format

• One File Per Submission– All IDSS Information

Consolidated

• Multiple Tabs– Not All Applicable During

Preliminary Benchmarking

Plan Responses

• Flagged Concerns– Plan Explanation

• Outliers Acceptable– Confirmation Needed

• Historical Log– Brevity!

Research Tools

• Outlier Toolbox– Case Reviews

• Internal Resources– SME

– Internal Reporting

• Vendor Tools

76

Example Rate Findings

• Outstanding Data

• Enrollment & Benefit Changes

• Supplemental Data

• Vendor Files

• ETL Issue

HEDIS 2017 Trends

• COL Did Not Drastically Increase with Cologuard@

• HPV Only Dropped 2% With Males Added

• MRP Increased 25 Points

• Biometrics - Admin Rates Up– ABA, WCC-BMI, CDC-BP, CDC-

Control

• SPC dropped 13 Points in Medicaid

STARS Means

Mean Rate: Absolute Change HEDIS 2017 vs 2016

-2 -1 0 +1 +2

CDC-Poor* OMWPCR*

ABABCS

ARTCBP

CDC-EyeCOL

77

FUA Results7 Day Follow-Up 10th Mean 90th

Medicare 6% 11% 20%

Commercial 6% 14% 22%

Medicaid 5% 13% 28%

30 Day Follow-Up 10th Mean 90th

Medicare 7% 15% 30%


Medicaid 6% 18% 37%

FUM Results7 Day Follow-Up 10th Mean 90th

Medicare 20% 38% 56%


Medicaid 24% 40% 65%

30 Day Follow-Up 10th Mean 90th

Medicare 33% 49% 69%


Medicaid 41% 55% 77%

HAI Aggregate Results

10th 50th 90th

CLABSI 0.26% 0.73% 1.00%

CAUTI 0.33% 0.77% 1.06%

MRSA 0.22% 0.64% 1.04%

CDIFF 0.40% 0.84% 1.04%

78

HAI Product Line Comparison

Product Line

CLABSIMean

CAUTIMean

MRSAMean

CDIFFMean

Commercial 0.70% 0.75% 0.64% 0.80%

Medicare 0.70% 0.78% 0.68% 0.81%

Medicaid 0.76% 0.82% 0.75% 0.87%

ECDS Measures• Not Widely Reported

– 3 Attest Submissions

• Low Volume of Members with ECDS Data Available

• CMS Encouraging ECDS Reporting

Questions

79

PCS & FAQ HighlightsChristy Patterson

Agenda

• What’s the difference?

• Rules Around PCS & FAQs

• Review of “Old Ones”– Still Applicable

– No Longer Applicable

FAQ

• Frequently Asked Questions– http://ncqa.force.com/faq

• Commonly Asked Questions

• Big Spec Clarifications and Updates

• Same Information Shared Publicly

80

PCS

• Policy Clarification Support– https://my.ncqa.org

• Plan/Auditor Specific Questions

• Clarifying Gaps & Gray Areas

• NOT Shared Publically

Submitting to PCS

Do’s & Don’ts

• Provide Context

• Specific Details

• Ask Question Directly

• Consider Answers to Similar Question

81

How Do I Know?

• Unofficially Official– Attest Considers Official

• Carry Forward When Applicable– GG or Spec Change=Likely

NA now

Those That Endure

<30 ReductionQ: Rates are populated in IDSS for measures where the EP <30. Can I reduce using the rate?

A: No, you can not reduce in the MY using a rate on an PY EP <30.

82

Membership ChangesQ: Can plans reduce using the PY rates regardless if there is a significant change to submission being reported in the current year?

A: If the submission ID has changed, a plan cannot reduce. If NCQA has determined the submission ID remains constant, yes the plan may reduce using the PY audited rates.

Board Certification AuditingQ: Please confirm that BCR is on a 3 yr audit cycle and the rules around auditing.

A:Yes it is on a 3 yr cycle UNLESS a plan is required to have it audited annually, there were significant changes in the reporting process, or is new to the audit firm.

Cervical Cancer ExclusionQ: Can we exclude a woman from CCS who was born male?

A: Yes if the person does not have a cervix they can be excluded. The documentation must be conclusive.

83

Tanner StageQ: Does documentation of “Tanner stage” meet for the physical exam or physical developmental history?

A: Yes for AWC only and it can not be used for both (aka pick one). It is not appropriate for W34 or W15.

EDD Causing ExclusionQ: For PPC, if we enter the EDD and it is not in the measurement window (11/6/PY-11/5/MY) the member is being exclude even though the delivery date is in the window. Is this correct?

A: Yes this was the intention.

BP and Medication ChangeQ: Please clarify “don’t use BP readings taken on the same day as a diagnostic test or procedure that requires a change in diet or medication”.

A: The intent is to identify diagnostic or therapeutic procedures that require a medication regimen, a change in diet or a change in medication.

84

No Longer Applicable

WCC Nutrition

Q: Can notation of “good appetite” be used to confirm nutritional counseling occurred.

A: Yes that documentation would count.

Spec Revision: Documentation related to a member’s “appetite” does not meet criteria.

Different Claims Same DOSQ: GG states use all claims (including ancillary claims) on DOS to identify the qualifying event. Is this correct?

A: Yes all claims for DOS should be used.

Spec Revision: Unless otherwise, the codes must be on the same claim.

85

Now it’s time for you to

What To Do Between Now & January 1st Manny Martin

WHAT’S PAST IS PROLOGUE

86

FIX IT LATER

• Anatomy of a Mix

SCHEDULED DEPARTURE

• Getting on the HEDIS Buss

DATA SCRUBBING

• Implementation Guide

• New Measures

• SME’s

87

DATA SCRUBBING

• Review Changes

• Digest New Elements

• Update Documentation

DATA SCRUBBING

• Source System Changes

• Is Source Reliable?

• Don’t Wait, Run Rates

PROVIDER INFO

• Mapping Review

• Myth Busting

• Welcome Back BCR

88

CONTRACTS

• Expedite Negotiations

• Finalize, Update (Now)

• Review Oversight

CAHPS

• Data Timeline

• CAHPS Form

• Secure Environment

SUPPLEMENTAL DATA

• Start Gathering Data

• Send Questions

• Notify Auditor

89

SUPPLEMENTAL DATA

• Validate, Fix, Recollect

• Work Timeline

• Avoid Corrective Action

TRAINING

• MRR Guides

• Hybrid Tools

• Abstraction Forms

ROADMAP

• Review Changes

• Mostly Static

• Identify SME’s

90

ROADMAP

• New Systems

• New SDS’s

• New RM Sections

KICK OFF CALL

• Expectations

• Gather Info

• Follow-up

“BY SEEKING, WE LEARN”

• PY Issue Log

• PY MRR Project

• PY FAR

91

FINAL THOUGHTS

• Don’t Wait

• Don’t Defer

• Don’t Cram

FINAL THOUGHTS

• Do Ask

• Do Revisit

• Do Plan

PREGUNTAS

hedis 2018 client conference welcome to san antonio! · • client-only conference calls objectives...

Documents