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
FAQ Directory: HEDIS
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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)?
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
· a new sample of 16 that proved to have zero errors
The auditor approved reporting.
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
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 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 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
12.16.2012 General Guidelines Some cells in the HEDIS 2013 Pharmacy Standard Pricing Table (SPT-Pharm) include dashes (-) instead of prices. Are the dashes equivalent to $0.00?
12.16.2012 Guidelines for Relative Resource Use Measures The table under step 9 on page 350 of the HEDIS 2013 Volume 2 should be used when assigning members to a RRU risk group. This year, the final risk score is rounded to 4 decimal places. In the table, Risk Group 1 is between 0.0000 and 0.2490. Risk Group 2 is between 0.2500 and 0.4990. To which risk group should a member be assigned whose risk score is 0.2495? The score does not fall in either group.
11.16.2012 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the Counseling for Nutrition and Counseling for Physical Activity indicators, do educational materials sent to members via mail or e-mail count toward the numerators?
No. The intent of the measure is to identify instances where a member received counseling for nutrition and physical activity; therefore, educational materials sent via mail or e-mail do not indicate that counseling occurred. The intent of including "member received educational materials" in the measure specifications is to allow for occasions where a provider gave educational materials to a patient during a face-to-face visit.
HEDIS 2013
11.16.2012 Medication Reconciliation Post-Discharge If a member's discharge is followed by a readmission or direct transfer to a nursing home or long term care facility, is the discharge included in the measure's denominator?
If there is evidence that the member remained in the nursing home or long-term care facility through December 1 of the measurement year, the discharge must be excluded from the denominator. If there is evidence that the member was discharged from the nursing home or long term care facility by December 1 of the measurement year, the discharge must be included in the denominator. Organizations may not assume that the member remained in a nursing home or long-term care facility through the end of the measurement year, based solely on the discharge status; there must be a method for identifying the members status for the remainder of the measurement year.
HEDIS 2013
11.16.2012 General Guidelines If a member was included in the denominator because of inaccurate claims data, may we remove the member from the measure? How do we do this?
Members who are in the denominator because of inaccurate claims data may meet the criteria for a valid data error. Valid data errors are identified only for hybrid measures during medical record review. If a member is in the denominator because of a claim with a code specified for the measure, the medical record must contain evidence that the member does not meet measure criteria; a silent chart is not evidence that the member does not have the condition being measured. If the valid data error criteria are met, the member should be removed from the sample and replaced with a member from the oversample.
Finding valid data errors is not intended to be a method of correcting improper billing practices, and they cannot be identified through supplemental data. Additional information and examples of valid data errors can be found in the Substituting Medical Records in the Guidelines for Calculations and Sampling (page 51).
HEDIS 2013