FAQ Directory

Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.

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2.15.2013 Eligibility for accreditation prior to establishing relationships Is an organization eligible for accreditation if it does not perform the functions specified within the standards and guidelines directly and has not entered into an effective service agreement with another entity to perform the function?

No. To be eligible the organization must perform the functions addressed in the Standards and Guidelines (e.g., QI, UM, CR, RR, and MEM, if applicable), either directly or through a service agreement. If the organization uses a service agreement, the agreement must specify functions covered and be effective before eligibility can be determined.

All other listed eligibility criteria also must be met.

2.15.2013 NA option for Medicare product line in Element B For QI 9 Element B, which requires organizations to adopt and distribute preventive health guidelines for perinatal care, care for children up to 24 months, care for children 2-19 years old, care for adults 2-64 years old and care for adults 65 years and older, is there an NA option for Medicare product lines that only serve individuals who are 65 years and older?

Yes. QI 9, Element B is NA for perinatal care, care for children up to 24 months, care for children 2-19 years old and care for adults 2-64 years of age for Medicare product lines that only serve individuals who are 65 years and older.

1.16.2013 Medical Record Review Validation What records are included in Group F (Exclusions)?

MRRV Group F (Exclusions) includes all optional and required exclusions and valid data errors found during medical record review. It does not include records excluded through administrative data or that belong to employees or their dependents. Other hybrid medical record exclusions that should not be reviewed in Group F are exclusions for CBP and the HbA1C Less Than 7% indicator. Because of the large volume, auditors review exclusion rates for these indicators separately. See the instructions in Volume 5, page 65 for reviewing CBP and HbA1c<7%.

HEDIS 2013

1.16.2013 Medicare Measures in the P4P Manual The MY 2012 measure set document updated on December 6, 2012, does not include any Medicare measures, but Medicare measures are in the P4P manual. Why are the Medicare measures not listed in that document any longer?

The HEDIS-based Medicare Star measure results are collected, aggregated and reported at the PO level using the same process as for the commercial P4P program, but they are not part of the commercial P4P program and are not listed in the P4P measure set document. MA results will be publicly reported; health plans may choose to use the results as the basis for performance incentive payments, although no standard P4P program for MA currently exists.

1.16.2013 Medical Record Review Validation What happens if a plan doesnt report any measures in a group?

The auditor selects one measure from each measure group that applies to the health plan, and exclusions from the exclusions group. If the plan doesnt report any measures in a particular group, the auditor will use his discretion, based on past performance and current progress, to determine if an additional measure should be selected from a group already used.

HEDIS 2013

1.16.2013 Medical Record Review Validation If a plan has one failed medical record during MRR validation, and a second sample also fails, do the measure and all the measures in that group receive an NR?

If a plan fails the test – one error in each of two samples – and cannot correct the error and resubmit the correction to the auditor, the plan may not use the Hybrid Method for reporting that measure. The plan can report the administrative rate or report an NR for that measure. The auditor must determine whether the error affects all the other measures in the group and their reportability.

HEDIS 2013

1.16.2013 All-Cause Readmissions (PCR) The MY 2012 P4P manual states that the All Cause Readmission measure will be collected as part of Medicare and is a mandatory testing measure for P4P, but this measure is not listed on the IHA Web site in the MY 2012 measure set.

Although P4P will collect the All Cause Readmission measure from health plans as part of the regular P4P clinical submission process, technically, it is an Appropriate Resource Use measure. As such, it is listed as a testing measure in the Appropriate Resource Use section. Note: Only health plans will submit results for this measure.

1.16.2013 Medical Record Review Validation Can the plan choose to rotate a measure that failed MRR validation?

The intent of measure rotation is to reduce chart review, not be a means to select the best rate possible. However, NCQA does not specifically prohibit this approach. Please note, if the reason for failing can be seen as possibly affecting other measures in the group, the auditor may elect to review those other measures.

HEDIS 2013

1.16.2013 Medical Record Review Validation If during MRR validation, a plan fails two samples, and informs the auditor they corrected the problem, what follow-up items are required to validate that the corrections were appropriate?

The auditor may use one or more methods to validate the chart error corrections. Follow-up actions should include:
· reviewing the error investigation and results
· reviewing policies and procedures to correct the error
· reviewing the corrected sample to ensure the updated numerator counts are correct and performing final hybrid rate review
· re-sampling charts for a new validation

Examples:

1. For the exclusions or data errors in the diabetes measure records, the auditor identified a pattern: she found two cases where the chart reviewer said the members did not have diabetes, but the chart showed that both members had elevated blood sugars and above average HbA1c results. One member had a PCP diagnosis of metabolic syndrome that placed him in the measure. The other member had a diagnosis of insulin resistance. The auditor required the plan to re-review all CDC exclusions and submitted charts for the remaining correct exclusions from the measure. The auditor approved reporting.

2. For the two MRRV samples, there were two errors found _ one in each sample. The auditor required the plan to do an analysis and demonstrate corrective actions.

The plan reported that one abstractor made the errors by incorrectly identifying the prior years CDC eye exams. The plan re-reviewed 100% of that abstractors hits and reversed 12 hits to misses. The plan had originally reported 100 admin hits and 200 hybrid hits for CDC eye exam. Of the 200 hybrid hits, 160 were measurement year eye exams, and 40 were negative retinopathy cases from the prior year. The auditor pulled another sample of 16, found no errors, and confirmed that the reported rate for the measure dropped from 73% to 70% as a result.

The auditor approved reporting.

3. The auditor found four errors in the first sample for AWC. He notified the plan and required them to do an analysis and demonstrate corrective actions. The plan submitted:

· the error investigation and results

· the policies and procedures that corrected the error
· a new sample of 16 that proved to have zero errors

The auditor approved reporting.

HEDIS 2013

1.16.2013 General Guidelines Are home-test kits that collect biometric values allowed for HEDIS reporting?

Only tests administered by a qualified provider may be used for HEDIS reporting. Self-administered tests (including home-test kits) where the patient performs the test and obtains the result are not eligible for use in HEDIS reporting.

Results from a home test kit where a qualified provider uses the kit to conduct a test or determine the results in the office are eligible for HEDIS reporting. If any home test is billed by a qualified provider using a code specified in the measure, it is eligible for use in HEDIS reporting; the code alone indicates compliance.

HEDIS 2013

1.16.2013 Medical Record Review Validation For measures that are heavily or entirely reliant on MRR data (e.g., COA, ABA, WCC, CDC BPs), if an organization attempts MRR validation and fails, or is able to retrieve a only small percentage of charts, can they report an administrative rate as low as 0% (assuming no other issues are identified)?

A low administrative rate, even 0%, can be reported, if the plan wants to submit such a rate and the auditor finds no bias or other problems in the administrative process.

HEDIS 2013

1.16.2013 Medical Record Review Validation Can an auditor substitute one member in the MRRV sample of 16 if that members chart cannot be found?

Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.

The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.

HEDIS 2013