Colorectal Cancer Screenings

Recently, there have been some quality of service issues arising from Colo-guard testing for our members. In the interest of helping you serve your patients, we wish to re-visit the subject of quality measures.

Care and performance assessment allows Premier Health Plan to continue its commitment to lead the region in high-quality, high-value care. Our focus on quality standards helps us remain a competitive choice for employers and a growing population of consumers, as well as meet requirements for our health plans. Our focus on quality and performance is part of what makes us a trusted provider of comprehensive care in our communities. The Healthcare Effectiveness Data and Information Set (HEDIS) helps us work toward that achievement.

HEDIS is a quality and performance assessment tool, required by the Centers for Medicare and Medicaid Services (CMS), which employs standardized measures set by the National Committee for Quality Assurance (NCQA). The review is conducted each January to May 15, and takes a retrospective look at care and services through claims, medical record reviews, and member surveys. The results guide us in developing quality initiatives, assessing performance, and building educational programs.

Premier Health Plan is making new strides in quality performance and member care through their participation in the Healthcare Effectiveness Data and Information Set (HEDIS):

  • Benefits to members - Our members thrive when we work toward and achieve excellence. The HEDIS initiative puts members in reach of preventive care and self-management, enhancing physician-patient relationships and resulting in quality outcomes.
  • Benefits to providers - Premier Health Plan is committed to supporting the essential role physician practices play in promoting the health of our members. HEDIS measures help us identify ways to bolster quality of care and performance that not only improves member outcomes, but maximizes a practice’s productivity and compensation. Premier Health Plan offers you the tools you need to effectively manage your patient population and our quality reward programs reward your efforts in this regard. 

One of the HEDIS assessments used is the Colorectal Cancer Screening measure. This measure is for patients 50 to 75 years of age who are members of a Medicare Advantage plan. It evaluates the percentage of members who had at least one appropriate screening for Colorectal Cancer based upon the below guidelines. Appropriate screening is an annual FOBT, annual FIT, FIT-DNA test (Cologuard®) once every 3 years, sigmoidoscopy in the last 5 years, or colonoscopy in the last 10 years.

How providers can help:

  • Documentation (date and result) of one or more of these screenings that satisfy for the metric: 
    • Colonoscopy during measurement year or 9 years prior to the measurement year; 
    • Fecal Occult Blood Testing (FOBT) during measurement year; 
    • Fecal Immunochemical Test (FIT) during measurement year;
    • FIT-DNA test (Cologuard®) during measurement year or 2 years prior to the measurement year;
    • Flexible Sigmoidoscopy during measurement year or 4 years prior to the measurement year
      • EXCLUSIONS from this measure by December 31st of the measurement year: 
        • Members who have a history of colon cancer OR 
        • Members who have had a total colectomy OR 
        • Members who are under Hospice care

Currently the FIT-DNA test (Cologuard®) is covered by Premier Health Advantage plans (Medicare Plans). 

Beginning in January 2018, the FIT-DNA test(Cologuard®) will be covered by all Premier Health Plan products that include: 

Medicare Plans: 

  • Premier Health Advantage (HMO)
  • Premier Health Advantage VIP (HMO and SNP)
  • Premier Health Advantage Choice (HMO-POS)

Commercial Plans (Large Group): 

  • Premier Health Employee Plan 
  • Premier Health Business Value 

Back to the December 2017 Issue