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Hedis and Outreach
 Michael’s comment sparked a few neurons for me so I’m going to digress a tiny bit. PCMH (Patient Centered Medical Homes) is a very popular buzzword. NCQA has this program that can be accredited. It’s a pretty good program to be honest. It really tries to get practices to use technology to improve health care. It focuses a lot on EHR’s (Electronic Health Records). They really want practices to think about population health and management.  They do the typical quality improvement language (Quality measures) which will transmit into HEDIS measures being used. The one weakness with this is that the population will have multiple HMO coverage’s (there are very few single HMO practices out there as far as I know). So you could have 3 different patients with different coverage’s. All these plans could have different requirements…. It’s really a mess the practice to keep it straight. Plus who the heck is going to do the quality metrics for these practices?? The medical billing coder?  This is where the DM companies need to work hand in hand with the practices.  They need tie the practice outreach with the DM outreach.  This is a huge opportunity for the DM companies. Do you really think the HMO is going to do this??They already are doing the metrics, they have the outreach capability.  Just how do you tie this together?  You need to tie the EHR, the doctor and the disease management together. You need the doctor to feed the EHR, the EHR to feed the DM and the DM to feed the EHR. Sounds easy, doesn’t it?There are very few companies that I know of that can do this at this moment.  
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HEDIS and Outreach
Disease Management is not dead… Contrary to some beliefs.  Disease management companies will be back stronger than ever. Why do you ask? Simply HEDIS performance improvement.  In order to show improvement you need to reach members to get those screenings, tests, and medication persistence. 
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HEDIS and Outreach Part 2

I think I'm going to talk a bit about stratification and HEDIS.  NCQA requires that members are stratified according to risk levels(HIGH, and other(Medium and Low depending on how you assess risk) for Health Plans and DM companies. Now you are suppose to outreach to these members based on their stratification. Common sense says you outreach to those High members based on the fact that they are usually the most unhealthy of your population. The conundrum is with HEDIS that stratification isn't a concern most of the time. It looks at chronic high risk members the same as low risk chronic members for a significant number of HEDIS measures. You could be diabetic or asthmnatic in very good health but still have considerable gaps.  Take me for example I have asthma, I use an inhaler as needed but hate taking a controller. I also usually forget my flu shot. But otherwise I'm in good health(my wife thinks I could lose a few). I'd be showing as having a few gaps much to Cigna's chagrin.  How do you convince me to close those gaps?  With a lot of HMO's since I'm low risk I probably wouldn't get much attention. But with HEDIS measures now the challenge is how to get me to change behaviors and close those gaps???  It's a challenge because if I'm not living at PCP practice who is going to remind and should they?  The way the market is appearing to move its looking at more preventative and screening as a way to get people healthier. Makes sense to be honest you want to catch things before they get worse.  Is it ideal?? In my opinion not really I don't think the standards really take into account how good your doctor is and how well they treat you.  I think some good practitioners out there may feel handicapped because of what they may be forced to do to get good ratings. The system isn't perfect and it is involving. Wellness is going to be a factor down the road... prepare for it.
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Document submission Part 5

Do not leave this to the last minute!!! The ISS tool while it does work pretty well most of the time can have the occasional hiccup. Nothing is more stressful than having something go wrong at the 11th hour and make a call to NCQA in a panic. IT support is pretty decent but it can take a bit to reach them. I highly suggest having everything ready a week early and submit the day before its due just to be safe. Also bookmark your pdf documents to help the auditor find what they need. Do not overload the auditor with documents. They really just want the exact documents they need to verify and nothing more. It’s a red flag if you try to blitz them with documentation.

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 NCQA Accreditation Pitfalls Part 4: Member File reviews
There is always a member file review for both Health Plan and Disease management. I can’t emphasize enough to have technical people involved when creating the specifications for the file pull. If you have questions or concerns get them addressed by NCQA well in advance of doing the file pull. Go over the pull with your assigned NCQA rep to make sure the contents are exactly what NCQA is looking for. Do not give NCQA the minimum number of members. The point of the review is to prove that you are following for established policies and procedures.  This should relatively easy to do with the documentation you have already provided. This can be a nightmare if you are inconsistent in policies and procedures.
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