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How Important is Your HEDIS Score as a Healthcare Provider?



Both independent primary care providers (PCP) and healthcare establishments (clinic, hospital, nursing home, etc.)must pay attention to their Healthcare Effectiveness Data and Information Set (HEDIS) score. This is necessary because health insurers rely on HEDIS to both create and update their own assessments about each healthcare provider individually.

If the major healthcare insurance providers in an area decide not to include a PCP in their list for coverage, that can have a crippling effect on the excluded healthcare provider’s business. Therefore, improving the HEDIS score is indeed more important that some healthcare providers may realize.As we delve deeper into the facts, the connection should start to make even more practical sense.

Why is the HEDIS Score So Integral?

The Healthcare Effectiveness Data and Information Set score holds more importance today than it did before the value-centric healthcare insurance contracts were introduced. More commonly known as risk contracts, these focus on allocating a certain budget to each patient depending on their healthcare plan and the necessary treatment. If the healthcare provider generates a bill that exceeds the allocated budget, then they will not be reimbursed by the insurer, beyond the predefined budget.

Although it was initially introduced with the MIPPA to solve acommon issue of excess billing by PCPs and other healthcare providers, risk contracts also present a different problem. Now that the healthcare providers are put on a budget and the risk of covering for the exceeded budget lies mainly with them, there is always a high probability that the patient will not receive the quality of care that they need.

The HEDIS score counters this issue as it clearly indicates how effective the provider has been so far in treating and caring for their patients with an assurance of qualityIf a healthcare provider’s HEDIS score dips low, then they will not be covered by most insurers. Since the HEDIS score is directly related to the patient’s quality of care, it acts as a protective shield against medical negligence for the patient.

What Makes Up the HEDIS Score?

As mentioned, HEDIS stands for Healthcare Effectiveness Data and Information Set, which means that the score is created after analyzing several sets of informational data from the provider’s history of effective and ineffective patientcareThere are several key performance indicators of HEDIS such as measurements and domain, data collection, HEDIS compliance audit, ICD-10, NCQA screenings, NVQA reports, and more.

These are analyzed and compared to first create and then maintain the healthcare provider’s effectiveness over time. Note that a healthcare insurer will not just consider the medical care provider’s overall score, but they will also consider their individual scores in the different facets of effective patientcare.

What is HEDIS Accreditation?

Only a handful of the best healthcare providers meet the HEDIS accreditation standards because it requires not only reaching, but also maintaining a very high HEDIS score. Notethat adopting a risk contract is almost essential to have a HEDIS accreditationalthough adopting one does not guarantee that you will receive the accreditation by defaulteither.

Healthcare providers that do manage to meet the standards will receive joint accreditations from the nation’s highest accreditation boards for their respective fields. The National Committee for Quality Assurance (NCQA) accreditation will be common to all.

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