Upcoming Medical Record Audits for 2013

Spring Access Surveys Begin Soon

Introducing EmblemHealth Neighborhood Care

Annual CAHPS Surveys Beginning

New Benefit Plans

Laboratory Services

Enhanced Autism Mandate Effective November 1, 2012

Medicaid and Medicare Updates

Claims Corner

Improvements to Our Online Doctor Search

What You Need to Know About
ICD-10 Today

Behind the Scenes

EmblemHealth, Among the Healthiest Companies To Work For

Early Elective Deliveries (Healthy Babies
Are Worth the Wait)

2013 Quality Program at EmblemHealth

Health Outcomes Survey

Brand vs. Generic:
Implications to Health Care

Tips to Reduce Antibiotic Use

Support the Fight Against Breast Cancer:
Promote Routine Screenings

Counseling Your Young and Adolescent Patients

Clinical Corner

News&Notes Archive


Upcoming Medical Record Audits for 2013

Adequate and proper medical documentation is essential for quality medical care. We conduct audits to review practitioner documentation and ensure compliance with Centers for Medicare & Medicaid Services (CMS) and New York State Department of Health (NYSDOH) regulatory requirements and to meet National Committee for Quality Assurance (NCQA) standards of patient care.

We work with our practitioners to review medical records and identify concerns, as well as offer tips for correct medical documentation when needed. We also provide appropriate preventive health guidelines to discuss with members. Here are some of the audits you can expect in 2013:

HEDIS 2013

Our Quality Management Department will soon begin its annual Healthcare Effectiveness Data and Information Set (HEDIS®) audit. HEDIS results are an integral part of the NCQA accreditation process. HEDIS measures allow consumers to easily compare the performance of health care plans.

HEDIS packets will be mailed to network providers in February 2013, requesting a total of approximately 40,000 medical records for standards of care measures, such as well-child visits and preventive breast cancer screenings, and for chronic illnesses including diabetes and hypertension. Strict procedures are followed during all phases of data collection, and the data is audited by NCQA-certified auditors to ensure that data requirements are followed.

NCQA has implemented new policy changes for 2013, including completion of the medical record review process by May 15, 2013, and the addition of the following new measures for 2013:

  • Asthma Medication Ratio.
  • Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications.
  • Diabetes Monitoring for People with Diabetes and Schizophrenia.
  • Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia.
  • Adherence to Antipsychotic Medications for Individuals with Schizophrenia.

If you are asked to submit medical records, please make sure that you follow the standards set by NCQA and NYSDOH and submit the records within the requested timeframes. Please refer to the EmblemHealth Provider Manual for medical record documentation requirements.

Higher HEDIS scores are usually the result of members receiving recommended health services and preventive health screenings. We ask you to remind your patients to schedule yearly exams and follow-up visits.

Prenatal/Postpartum Care Audit

NYSDOH requires all Medicaid Managed Care plans to provide all pregnant members with comprehensive prenatal care services through their participating practitioners. To meet this requirement, we annually review a sampling of medical records for our pregnant Medicaid members. This year's audit, covering service year 2012, will begin in March 2013.

For medical records reviewed in 2011, covering service year 2010, we found an overall improvement in the number of practitioners meeting the benchmark score of 90 percent or greater. Thank you for your efforts.

Our practitioners did not fare so well in assessing high-risk factors and documenting them in patient medical records. This warrants further improvement. Assessments must include a notation of discussion and counseling with the pregnant member on the following:

  • Dental care
  • Newborn HIV testing
  • Food/shelter resources
  • Parenting skills
  • Newborn screening

Additional prenatal information and resources, as well as many other topics, may be found on the New York State Department of Health Web site.

Primary Care Physician Audit

Collection of medical records for the 2013 Primary Care Physician audit has ended, but the review and evaluation continues for year 2012. To comply with NYSDOH regulations, as well as NCQA accreditation requirements, we perform an annual review of the medical records of a sample of network practitioners specializing in internal medicine, pediatrics and obstetrics/ gynecology.

To meet the NCQA standards and fulfill audit requirements, a practitioner must obtain a score greater than 90 percent. For the 2012 audit, covering service year 2011, 86.3 percent of our network practitioners met the benchmark for standards of care.

The largest observed improvement in documentation for adult records was in the High Risk Behavior and Anticipatory Guidance category for practitioners who documented a discussion on violence and abuse. There was an increase in documentation of 21.31 percent from 2010 to 2011. An area that still requires improvement is in the category of Preventive Health Guidelines for documenting a hearing screening annually. Please go to our Clinical Practice Guidelines for a complete list of age-appropriate screenings.

Additional information and resources on medical record documentation standards can be found in our Provider Manual.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 Home  |  Behind the Scenes  |  Printer Friendly Page  |   Print Full Issue