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Improving Your Incentive Earnings With Quality Care

Date: 01/09/18

The Healthcare Effectiveness Data and Information Set (HEDIS) is a key tool in assessing the availability of quality, patient-centric care. Health plans, including Louisiana Healthcare Connections, collect data from providers via medical records requests and report that data to the National Center for Quality Assurance (NCQA).

Physician-specific scores are used as evidence of preventive care from primary care offices. These rates are used as a basis for physician incentive programs. These programs reward providers based on their individual scoring of quality indicators such as those used in HEDIS.

This means that improving your HEDIS scores can improve your quality incentive earnings! Louisiana Healthcare Connections, in 2016, paid nearly $8 million in Per Member Per Month (PMPM) incentives to its network providers for achieving certain HEDIS measures.

Here are tips on how to improve your HEDIS scores in our incentivized HEDIS measures:

Adolescent Well Care (AWC)

Children ages 12-21 should receive at least one comprehensive well visit per year. (Note: This visit may be completed by a Primary Care Provider (PCP) or OB/GYN.)

Tip: Complete and document the patients’ health history, physical development history, mental development history, physical exam and health education/anticipatory guidance.

Chlamydia Screenings in Women

Sexually active females ages 16-24 should be screened for chlamydia each year. (Note: “Sexually active” is identified as any member who had a pregnancy test, had any other STD testing completed and/or had a prescription filled for contraceptives.)

Tip: The CDC recommends the non-invasive nucleic acid amplification test (NAAT) for chlamydia screening, but chlamydia tests can be completed using any method.

Well Child Visits, Ages 3-6 Years

This measure evaluates the percentage of patients ages 3, 4, 5, or 6 years who had at least one comprehensive well care visit per year.

Tip: The visit must be with a PCP (pediatrician, family practice or OB/GYN), even though the PCP does not have to be the practitioner assigned to the child. Remember – assessment or treatment of an acute or chronic condition do not count toward the measure, and do not include services rendered during an inpatient or ED visit. A comprehensive well child visit includes the following components:

  • A health history
  • A physical developmental history
  • A mental developmental history
  • A physical exam
  • Health education/anticipatory guidance

Comprehensive Diabetes Management (CDC)

Members age 18 and over should have diabetes-specific care. This measure demonstrates the percentage of patients ages 18-75 with diabetes (Types 1 and 2) who were compliant in specific submeasures (detailed below).

Tip: Make sure you obtain and document the following:

  • Annual HbA1c or more frequently as needed (The goal is < 8.0%.)
  • Indicate results of HbA1c:
  1. 3044F < 7.0%
  2. 3045F between 7.0-9.0%
  3. 3046F > 9.0%
  4. Reminder: Louisiana Healthcare Connections reimburses for HbA1c testing performed in the provider office. (Use CPT codes 83036 and 83037)
  • Annual medical attention for Nephropathy (CPT 82042, 82043, 82044, 84156)
  • Retinal eye exam (dilated)
  • Controlled blood pressure (<140/90)

Adult Access to Ambulatory Care

This measure evaluates the percentage of patients age 20 and older who had at least one ambulatory or preventive care visit annually.

Tip: The services that count for this incentivized measure include outpatient evaluation and management (E&M) visits, consultations, assisted living/home care oversight, preventive medicine and counseling. To ensure increased earnings for this measure, call the adult patients in your panel to schedule their annual wellness visits.

We’ve Got Tools To Help You Succeed!

Don’t forget – you can use our secure Provider Portal to access valuable, timely data reports to help you identify and address care gaps, HEDIS performance measures, PMPM incentive earnings, and ED utilization rates among your patients – our members! If you need assistance registering for the Provider Portal, or if you would like to request portal training for your staff, please contact your dedicated Provider Consultant or call Provider Services at 1-866-595-8133.

We also offer many free training and educational opportunities for providers, both on-site and via webinar. These trainings, many of which offer CEUs, are designed to support you in delivering quality, accessible and integrated care to your patients – our members! If you’d like to register for a training session, visit www.EnvolveU.com. Questions about training opportunities and requests for on-site training can be sent via email to clinicaltraining@cenpatico.com.