Written by Terry Kennedy, Senior Search Consultant.
As one of the nation’s premier HEDIS staffing agencies, CareNational is always committed to providing the best service possible to our candidates and our clients. This includes continuing education through interactive conversations with contacts from both the client and candidate perspective. As the 2015 HEDIS (Healthcare Effectiveness Data and Information Set) season approaches, CareNational is dedicating a series of blogs to help health plans. Since we are experts in providing top-tier talent, but not in actually doing Quality Improvement or HEDIS functions, we are tapping into the extensive knowledge of our candidates using an ‘Ask the Expert’ format.
I recently spoke with Belinda B. about the difference between HEDIS Abstraction and HEDIS Over-reading. Belinda is a seasoned HEDIS Nurse from Florida, with over 6 years of HEDIS experience in a variety of roles, including HEDIS Abstraction, Over-reading and HEDIS Project Management.
Belinda explained there are several different phases in the timeline associated with the National Committee for Quality Assurance (NCQA) HEDIS process. Prior to the HEDIS Data Abstraction the medical records or claims must be collected, either by physically assembly of medical records onsite or through data collection of electronic medical records (EMR).
Once the records have been compiled, the actual Data Abstraction is performed either onsite at providers’ offices or remotely from a corporate office setting or even home office. According to a recent HEDIS worker survey, the majority (62%) of respondents listed telecommuting / work-from-home as the most preferred work setting, although some enjoyed the interaction and education of working at provider offices. The Abstractors conduct a detailed review of medical charts and insurance claims for hospitalizations, medical office visits, and other procedures, to determine if the quality of care measures, as defined by NCQA for that year’s HEDIS audit, have been met.
What are they reviewing? Each year NCQA determines a variety of specific quality measures to be audited, and while some are consistent each year, others are added or modified based on changes in healthcare quality. The 2015 HEDIS audit will cover 81 quality measures across 5 domains of care, and over 90% of health plans will use it as a tool to measure performance standards. These measures assess how well the organization carried out specific functions or processes. For example, the HEDIS 2014 measures included “Medical Management for People with Asthma, Controlling High Blood Pressure and Comprehensive Diabetes Care.”
Once charts have been reviewed for each of these quality measures, and the information has been abstracted into raw data, the next step is HEDIS Over-reading. This function is performed by highly experienced and skilled HEDIS Abstractors, as they are actually performing quality control checks by reviewing the work of field Abstractors. The Over-reader is responsible for verifying that the data compiled is accurate for the measures outlined. They must be experts in HEDIS Rules of Abstraction and ensuring all work is in compliance with NCQA guidelines. If any errors are found, the Over-reader must carefully document the error as well as the specific changes that were made. Excellent documentation skills are critical for HEDIS Over-readers as they are the second set of eyes on the abstracted medical data. In essence, they validate the work done by Abstractors.
The work done by each of the individual clinical and non-clinical HEDIS staff adds up to a big difference. Whether it’s the Nurse Abstractor driving to a never-ending parade of doctor’s offices, the coder pouring over electronic records at a home computer, or the Over-reader making sure no errors slip past their watchful eyes, they all contribute to improved healthcare quality. For members and patients, attaining appropriate scores for assigned HEDIS measures is directly linked to cost-effective delivery of care and better health outcomes. For a large health plans, that can translate into millions of dollars in reimbursement from sponsored healthcare programs like Medicare and Medicaid.
As stated initially, CareNational is an expert in HEDIS staffing and career search consultation in these specialized areas, but we do not perform the functions ourselves. So how did we do? Did you find this information useful? We love feedback!
A special thanks to Belinda B. for providing her insight from multiple aspects of the HEDIS project. If you would like to speak with Belinda about these topics, or for career/consulting opportunities, contact the author, Terry Kennedy, an experienced Senior Search Consultant in our Scottsdale, AZ office.
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