2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Quality Improvement Programyear <strong>and</strong> a few performance measures requirehealth plans to find <strong>and</strong> report on data for previousyears. The HEDIS ® data requirements are veryspecific <strong>and</strong> cannot be changed by the health plan.Before submitting the report to NCQA, HSD, <strong>and</strong>CMS, it is thoroughly reviewed by NCQA-certifiedauditors to ensure that it was prepared correctly.NCQA <strong>and</strong> regulatory agencies frequently publishHEDIS ® results in public forums so that existing<strong>and</strong> potential health plan purchasers <strong>and</strong> memberscan compare results.How does HEDIS reporting impact the practicesetting?Health plans rely on the claims submitted bypractice sites to prepare the HEDIS ® report. Whenclaims are not coded correctly, they cannot be usedfor reporting purposes. When a health plan cannotfind the claims data, a medical record searchbegins by identifying those providers that provideda service to members selected for the HEDIS ®report.These providers are given a list of patient names<strong>and</strong> asked to make available the medical recordsfor health plan staff to review or, when this is notpossible, make copies of selected medical recordpages. Because medical records are confidential,many health plans obtain authorization to reviewmedical records when a member signs up forbenefits. Health plans submit the audited HEDIS ®reports to NCQA in June of each year, <strong>and</strong> typicallybegin preparing at least six months before the Junedeadline. Medical record data collection can beginany time during the first quarter of the calendaryear.How does <strong>Presbyterian</strong> use the HEDIS reportingsystem?For the past several years, <strong>Presbyterian</strong> hasintegrated the HEDIS ® performance measures intoits QI program to gauge the success of its clinical<strong>and</strong> service activities. For example, HEDIS ®measures are used to determine the success of<strong>Presbyterian</strong>’s disease management programs fordiabetes <strong>and</strong> coronary artery disease. The annualmember satisfaction survey measures, known asCAHPS ® , is used to monitor improvement activitiesin customer service <strong>and</strong> getting care quickly.Selected HEDIS ® <strong>and</strong> CAHPS ® measures wereincluded in the <strong>Presbyterian</strong> QI program to rewardthe provider network for providing quality care.12-132014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
Change language