HEDIS® Primer for Diabetic Eye Exams

HEDIS® stands for Healthcare Effectiveness Data and Information Set. It is a set of 81 health care performance measures across five domains of care. The National Committee for Quality Assurance (NCQA) oversees the development and implementation of the HEDIS tool. The measures grade how well a health plan performs in areas of quality of care, access to care, and member satisfaction.

HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis. Health plans combine their HEDIS scores with CAHPS® (Consumer Assessment of Healthcare Providers and Systems) scores and NCQA Accreditation standards scores to receive a Health Insurance Plan Rating by the NCQA. The NCQA ratings list includes commercial payers, Medicare, and Medicaid plans.

This FAQ addresses the following:

1. What is HEDIS?
2. What is the Health Insurance Plan Rating, and how does it work?
3. Who uses HEDIS?
4. Are third party payers required to submit HEDIS data to the NCQA?
5. How do ophthalmology and optometry participate in HEDIS scores and Health Insurance Plan Ratings?
6. How does the health plan know that the patient received these services?
7. How does a primary care provider (PCP) fit in this matrix?
8. Why are PCPs concerned about this HEDIS measure?
9. How are PCPs trying to remedy this situation?

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