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HEDIS and the Importance of Medical Review Professionals

As the healthcare industry continues to move from a fee-for-service model to an outcome based model, properly trained medical review professionals are becoming ever more crucial. Healthcare professionals, insurance companies, and patients are now working together to find the most cost and medically effective treatments. This is where the Health Effectiveness Data Information Set (HEDIS) comes into play.

What is HEDIS?

HEDIS is a tool used by the majority of health care plans to gauge the effectiveness and performance of healthcare services and was developed to provide consumers with an accurate comparison of health care plans. Based on eighty-one sets of information from five different domains of care, HEDIS provides a great “apples-to-apples” comparison of how well health plans are performing. Once the information has been collected, it is rigorously audited by certified professionals.

The NCQA Performance Measurement Committee, made up of individuals from health plans, employers, and consumers, updates the HEDIS measures each year, based on what all parties deem relevant.

Why do we need HEDIS?

With a patient population demanding affordable and effective healthcare it is becoming increasingly important for both health plans and medical professionals to provide medically relevant, cost-effective health care to patients.

Who uses HEDIS?

HEDIS scores are used by health plans to measure where they need to improve and as a credential when looking to partner with new employers and consumers. They are also used by MCOs to gain new state Medicaid/Medicare business and funding through CMS.

What are medical review professionals?

Medical review professionals are trained throughout their careers as to what types of care are necessary for certain diseases, injuries, and other health issues. Professionals trained to understand the complex connection between payor, medical professionals, and providers are vital to the process of developing a care plan that is beneficial for the patient while being financially responsible.

Thousands of healthcare professionals are hired each year by health plans to help conduct their HEDIS reviews by collecting patient health records and reviewing them in accordance to the 81 measures mentioned above.

What does this mean for you?

For each player involved in the healthcare care industry, no matter what form; payor, provider, government or legal entity- it is important to have the right human capital in place to mobilize this effort of cost-efficient health care. Improper medical coding and claims by physicians and other licensed healthcare professionals can result in major cost burdens for patients.

It is important for providers, employers, and consumers alike to be aware of what health plan is the best option for them in their quest for cost effective healthcare solutions. HEDIS allows consumers to make true apples-to-apples comparisons on health plans and find the right balance between effective care and cost effectiveness. Medical review professionals are a critical component of this process; ensuring HEDIS is properly up-to-date and saving healthcare providers, health plans, and patients money.

Judge is a leader in sourcing for HEDIS, medical review, care/case management, medical coding, provider & member outreach, and other allied healthcare professionals. Contact Judge Healthcare at (678) 987-9897 or via email to learn more.

By: Mathijs Mesters

Topics : Articles, Healthcare, HEDIS, Medical Review Professionals

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