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Provider Resources

January 2020

Table of Contents

Evaluating Quality of Care through HEDIS
Programs for Health and Well-Being

Evaluating Quality of Care through HEDIS®

At Network Health, our mission is to create healthy and strong Wisconsin communities. Our relationship with providers plays a vital role in that mission, so we make it a priority to provide you and your staff with tools to streamline the process of serving our members. Our commitment to quality isn’t about awards, excellent quality ratings or accreditations. Yes, we continue to exceed the industry's highest standards, but at Network Health we put the spotlight on our members and making sure they get the right care, at the right place and at the right time.

What Is HEDIS?
The National Committee of Quality Assurance (NCQA) defines HEDIS as “a set of standardized performance measures designed to ensure that the public has the information it needs to compare organization performance.” HEDIS is used to examine care provided for several conditions across all body systems; addresses members’ access to, and satisfaction with, various health care services; and measures utilization for specific procedures and care settings.

How Are the Scores Used?
Results from HEDIS data collection are used to measure quality-improvement processes and preventive care programs. The information lets us know where successes are and which areas may have room for improvement.

How Can I Improve My HEDIS Scores?
• Submit claims with proper ICD-10 or CPT codes for all services rendered.
• Document services completely to accurately reflect all services billed.
• Ensure medical records requested for HEDIS audits are processed and sent in a timely manner.

Programs for Health and Well-Being

Our health management team consists of three unique areas.
• Health Coaching
• Condition Management
• Care Management
Each area is staffed by Network Health professionals with the appropriate knowledge and expertise to serve as health coaches, condition managers and care managers. They work one-on-one via phone to address the individual needs of our members. Member participation is voluntary, and participants may opt out at any time.

Health Coaching
The health coaches at Network Health specialize in motivation and encouragement to help our members meet their personal health goals. Common topics include the following.
• Nutrition
• Weight management
• Tobacco use
• Blood pressure
• Cholesterol
• Blood sugar
• Sleep
• Alcohol consumption

Condition Management
Condition management nurses at Network Health empower members to take charge of their chronic conditions and be the healthiest they can be. If a member has asthma, COPD, diabetes, heart disease or heart failure … we can help.

Care Management
Care managers, comprised of nurses and social workers, can help members who are facing difficult diagnoses or complex medical/behavioral health conditions. This team helps members get the health care that is needed at the right time and, just as important, at the right place. Care managers can assist with the following.
• Reviewing medications or treatment plans
• Helping identify signs of worsening health condition and what next steps should be
• Working with and coordinating care with members’ health care providers
• Ensuring caregivers feel included

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