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:
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.
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:
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).