hedis 2018 client conference welcome to san antonio! · • client-only conference calls objectives...
TRANSCRIPT
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HEDIS@ 2018Client Conference
Welcome to San Antonio!
HEDIS 101Carlo Teano & Jenna Morgan
Introductions
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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
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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
• High-level HEDIS overview
• Attest audit approach • Tools and resources
• Audit expectations
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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
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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
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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
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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
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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
• High-level HEDIS overview
• Attest audit approach
• Tools and resources• Audit expectations
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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
• High-level HEDIS overview
• Attest audit approach
• Tools and resources
• Audit expectations
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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
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Enjoy the Workshop!
HEDIS@ 2018Client Conference
Welcome to San Antonio!
Welcome to San AntonioBob Oakleaf
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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
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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
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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
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Affinity Event
• Dave & Buster’s• Games, Food, Wine & Beer• Shops At Rivercenter• 6-9 PM, Wed Oct 11th
Inovalon
HEDIS 2018 Specifications UpdateMelissa Sheesley
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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
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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
Effectiveness of Care
• WCC – “appetite” ≠ Nutrition counseling
• IMA – added 2-dose HPV
• BCS & COL– Required Exclusions
• BCS: Digital Breast Tomosynthesis
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Effectiveness of Care
• COA – Several minor clarifications
• CWP/URI – Revised episode date
• Clarification about ED or Observation visit IP Stay
Effectiveness of Care
• 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
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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
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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)
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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
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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
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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
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Questions
2018 Strategies for SuccessLaura Hart
Objectives
• Challenges of HEDIS 2017
• Focus HEDIS 2018
• Tools for Success
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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-
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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
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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
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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?)
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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
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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
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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
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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?
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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
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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
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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
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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
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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)
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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
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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
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Hypertensive Retinopathy
Hypertensive Retinopathy
HbA1C Date Error
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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
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WCC
• Developmental assessments do not count
• Acute/chronic conditions do not count
Nutrition Counseling Errors
Physical Activity Counseling Errors
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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
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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
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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
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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
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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?
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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
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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
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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
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#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
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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
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EMR Challenges• Access
• Data structure
• Systems variability
• Provider abrasion
• Member targeting
• Mapping
• Enterprise support
OBJECTIVES
• What SDS are plans using most?
• What’s Non-Standard?– How do I pass PSV?
• What’s the word on ECDS?
Non-Standard SDS
• Capture missing service data– Not received via admin
sources, manual
• Irregular submission, unstable format
• Follow clear P&Ps
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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!
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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 Non-Standard?– How do I pass PSV?
• What’s the word on ECDS?
What’s an ECDS?• Member database network
– PHI, healthcare experiences
• Care-related activities– Evidence-based
– Quality management
– Outcome reporting
• Automated quality metrics
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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
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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
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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
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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
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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
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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
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RE-CAP
• What SDS are plans using most?
• What’s Non-Standard?– How do I pass PSV?
• What’s the word on ECDS?
QUESTIONS ?
Benchmarking Process & Measures TrendsKevin Gregory
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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
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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
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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
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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
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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%
Commercial 8% 18% 28%
Medicaid 6% 18% 37%
FUM Results7 Day Follow-Up 10th Mean 90th
Medicare 20% 38% 56%
Commercial 25% 46% 64%
Medicaid 24% 40% 65%
30 Day Follow-Up 10th Mean 90th
Medicare 33% 49% 69%
Commercial 42% 61% 78%
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%
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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
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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
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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
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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.
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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.
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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.
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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.
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Now it’s time for you to
What To Do Between Now & January 1st Manny Martin
WHAT’S PAST IS PROLOGUE
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FIX IT LATER
• Anatomy of a Mix
SCHEDULED DEPARTURE
• Getting on the HEDIS Buss
DATA SCRUBBING
• Implementation Guide
• New Measures
• SME’s
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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
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CONTRACTS
• Expedite Negotiations
• Finalize, Update (Now)
• Review Oversight
CAHPS
• Data Timeline
• CAHPS Form
• Secure Environment
SUPPLEMENTAL DATA
• Start Gathering Data
• Send Questions
• Notify Auditor
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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
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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
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FINAL THOUGHTS
• Don’t Wait
• Don’t Defer
• Don’t Cram
FINAL THOUGHTS
• Do Ask
• Do Revisit
• Do Plan
PREGUNTAS