September 2025 Provider's Corner

Nurses are the heartbeat of healthcare. Their compassion, skills and dedication affect the patient’s overall quality of care. The role of the nurse extends far beyond routine tasks and are essential for the patient’s experience and satisfaction.

Here are some opportunities for nurses to drive meaningful improvements:

• Expand patient access by assisting patients in navigating their healthcare. Help the patients feel impowered by assisting them with access to Telehealth services, and self-care educational resources.
• Provide emotional support by creating a calming confidential environment where patients can share concerns. Patients, feeling supported and involved can lead to improved healthcare and health care outcomes.
• Communicate with clarity by allowing patients time to express concerns through verbal and nonverbal cues and ask open ended questions to avoid steering the conversation.
• Encourage preventative care by offering education and counseling on vaccinations, and health screenings and services.

Nurses are often a patient’s first interaction to a health facility. When patients feel safe, self-confident and supported by their healthcare team, they achieve better health results.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an annual survey sent to members/patients to measure satisfaction with their providers and healthcare systems. The goal of CAHPS is to capture accurate and complete information about the member-reported experiences.

The CAHPS survey asks patients to rate the overall quality of care on a scale of 1-10. So, it is important to encourage patients to schedule their routine appointments for check-ups, or follow-up visits in advance. Ensure that all open care gaps are addressed during each visit and any prior authorizations or referrals for patients are prioritized.

Incorporate the following tips into your daily practice:

• Call patients about test results as soon as possible.
• Ensure that all specialist referrals notes are in patient’s medical records and review with patients during office or telehealth visits.
• Review current medication with patients.
• Make sure patients know how to reach their PCP with questions.  

Visit our CAHPS website page for more information. on CAHPS.

October is Breast Cancer Awareness Month. In 2025, approximately 316,950 women in the United States will be diagnosed with breast cancer, and 42,170 are expected to die of the disease, according to the National Cancer Institute. From 2015 to 2021, the five-year survival rate for women diagnosed with breast cancer was 91.7%. 

It’s important to get members ages 40–74 who were recommended for routine breast cancer screening and had one or more mammograms between October 1, two years prior, through December 31 of the measurement year scheduled for a breast cancer screening.

Breast Cancer Screening CPT: 77061-77063, 77065-77067

Note: NCQA transited breast cancer screening (BCS-E) to an ECDS (electronic clinical data systems) measure in 2023, using the appropriate codes to meet the measure administratively is critical moving forward.  Click on the hyperlink for more information about NCQA ECDS. 

Exclusions:

• History of bilateral mastectomy or both right and left unilateral mastectomies any time during the member’s history through the end of the measurement period.
• Members who had gender affirming chest surgery with a diagnosis of gender dysmorphia.
• Members ages 66 and older who are in a long-term institution of SNP, have frailty and advanced illness, and are receiving palliative care.
• Members who use hospice services/benefits or who die any time during the measurement period.

HEDIS® Improvement Tips:

• Provide education and benefits regarding early detection of breast cancer through routine mammograms.
• Consider a standing order of breast cancer screenings for members ages 40-74.
• Encourage all women ages 40-74 to get a mammogram because early detection of breast cancer is key to survival.
• Submit the appropriate mastectomy code to exclude the patients from this measure if this diagnosis has occurred in their health history.
• MRIs, breast ultrasounds or biopsies DO NOT meet standards for this measure.
• Document date of last mammogram screening at annual preventative visit.
• Follow up on outstanding orders when no report has been received.

For more information about HEDIS, please visit the Our new 2025 HEDIS Provider Reference Guide is available.