How a Health Plan Closed Care Gaps and Increased Provider Engagement with Electronic Clinical Quality Validation

Background

Health plans that participate in quality improvement programs and risk-adjustment initiatives, such as HEDIS®, depend on clinical data to ensure timely identification and proactive closure of member care gaps.

Unfortunately, typical clinical data acquisition approaches—fax machines, phone calls, and vendors contracted to “chart chase”—are costly and inefficient. The burdens caused by these analog or outsourced solutions often result in poor rates of provider engagement, failure to improve quality care ratings, and more members vulnerable to critical care gaps.

A large national health plan engaged with Availity to map an automated and entirely digital solution to capture the appropriate clinical data and collaborate with providers to identify and close potential quality care gaps

Solution

The health plan engaged with Availity to map an automated and entirely digital solution to capture the appropriate clinical data and collaborate with providers to identify and close potential quality care gaps.

The Clinical Quality Validation (CQV) application within Availity Essentials, the company’s multi-payer provider engagement platform, notifies providers of care gaps and allows providers to submit the appropriate clinical data to close the gaps electronically. Utilizing the CQV app, health plans can:

• Notify Providers: Rather than relying on sending letters or faxes, health plans can notify providers in their workflow about open care gaps via the Availity Essentials notification center.
• Reduce Administrative Burdens: Within the CQV app, providers can quickly see all open care gaps within a consistent workflow. Each gap is closed by completing a pre-populated patient form and attaching relevant electronic health records.
• Improve Data Quality: The CQV app includes contextual information to ensure providers clearly understand what clinical data are required, eliminating the chances that the wrong or incomplete records are sent to the health plan.
• Capture Medical Records Electronically: After the provider submits the record, Availity sends the health plan the medical documentation and the provider’s completed form, allowing the health plan to complete the process quickly.

Additionally, the CQV app features “smart” forms that ensure that all provider responses are validated as complete and accurate the first time. For example, if a requirement is within the measurement year, a validation prompt will alert the provider if they put in a date from the previous year. Users can also use quality measure-specific exclusions to ensure care gaps are quickly identified. Finally, providers can easily attach medical records to the validation form prior to
submission to the health plan.