HEDIS

The Centers for Medicare & Medicaid Services (CMS) has directly linked reimbursement for healthcare services to patient outcomes. Consequently, health plans and providers are being asked to close gaps in care and improve overall quality.

Initially designed to be a set of performance measurements or indicators used to compare organizations “apples-to-apples,” the Healthcare Effectiveness Data and Information Set (HEDIS®) measures have evolved to become the gold standard in managed care performance measurement and is an integral component in the assessment of CMS Star ratings, health exchange participation, and incentive programs for Medicare health and prescription drug plans.

Industry acceptance of the HEDIS methodology, the transparent nature of the measurement calculations, and their stability over time make it an ideal framework for the identification of members with manageable gaps in care and a foundation for on-going quality initiatives.

By using our solution, HEDIS measures can run on the standard calendar year as required by the National Committee for Quality Assurance (NCQA), and also on any user-defined analysis period. This provides health plans with a tool to continuously measure, monitor, and manage HEDIS rates throughout the year as well as to meet additional off-cycle compliance requirements.

Our solution enables identification of member level gaps in care, provides an option to integrate member-predicted risk and resource utilization, and can facilitate member/provider communication. We offer summary reports that display health plan measurement results in a format consistent with the NCQA submission requirements, as well as detailed member level and claim level reporting.