Understand the relationship between physician referrals and HEDIS measures. This will help you keep referring providers happy.
Net-net. Unless the “referred to” doctor’s office returns the visit notes “note or letter” – the referring doctor cannot meet their HEDIS measure requirements.
If they don’t meet the HEDIS requirements, their payers will not improve their reimbursements next year. Payers are measured by STAR ratings.
If the payers are not getting good ratings, they won’t increase the reimbursement rates of the providers.
It’s a circle.
On this page
It’s a much larger topic. NCQA collects HEDIS data from health plans, health care organizations and government agencies.
HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance. HEDIS Measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes.
Know this – HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis.
Data is reported to NCQA every June of the reporting year (e.g. June 2019) but that report is for the prior year ( eg 2018) for providers.
What are STAR Ratings?
The Centers for Medicare & Medicaid Services (CMS) uses a five-star quality rating system to measure the experiences Medicare beneficiaries have with their health plan and health care system — the Star Rating Program. Health plans are rated on a scale of 1 to 5 stars, with 5 being the highest.
What does this have to do with a referral?
Physicians refer patients for clinical reasons (care giving) and also are required to make outbound referrals to improve their own reimbursements.
Providers need to prove they referred patients to appropriate specialists. The proof is in the consult notes that they receive back from the provider they referred to.
This closes the referral loop for them. They can then get higher standings with their own payers.
This in turn allows payers to prove that their “members” received appropriate referrals and care. This allows them to get higher ratings and therefore are chosen by more employers for their plans.
Follow the money and you will understand why
E.g. one of the HEDIS measures is Comprehensive Diabetes Care (CDC) – Retinal Eye Exam for patients with Diabetes type 1 or 2.
What is required to achieve good marks for this measure?
A note or letter from an ophthalmologist, optometrist, PCP or other healthcare professional indicating that an ophthalmoscopic exam was completed by an eye care professional, the date when the procedure was performed and the results
The primary care physician / doctor has a patient come in with diabetes types 1 or 2.
Here, the PCP notices that the patient needs a referral to an eye doctor.
They immediately refer this patient to the eye doctor (ophthalmologist).
However, they need this “note or letter” before they can claim to the healthcare payer that they met this measure and should be given high marks.
So, unless referred to doctor’s office returns the visit notes “note or letter” – the referring doctor cannot meet this measure.
Once you understand this cycle, you will know why closing the referral loop is so important.