HEDIS 2013

With the books closing on our 2013 HEDIS® data collection projects and with a fresh copy of the 2014 HEDIS® Technical Specs in hand (actually in both hands, this thing is getting War and Peace big!), I thought it would be a good time to reflect on the year and what we learned.

  1. Failing a Medical Record Review Validation should now be virtually impossible. Apprehension and fear abounded as the launch of HEDIS® 2013 drew near with the new deadlines and rules for the MRRV. In reality, the new rules actually improve a health plan's chances of passing the audit. True, execution and adherence to data collection and abstraction timelines are more important than ever, but even plans that start data collection as late as March should have 8-10 weeks to collect and abstract for their samples. This should be more than enough time to do a very good job on hybrid data acquisition.

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    Knowing which measures are going to be reviewed on May 1st, plans and/or their vendors can begin the process of audit prep in parallel to the final weeks of collection. Plans with greater resources typically don’t wait for the measure list to come out as they over-read 100% of any measures they suspect might be pulled. By May 15th, plans, informed by their auditor’s input from the convenience samples, should be making decisions on which numerator hits they may want to back out of compliance due to missing or incomplete documentation before sending the lists to auditors. Once the lists are sent to auditors, there should be very little uncertainty about whether documentation exists to support numerator hits.
  2. Avoid the temptation to be too conservative. I have no doubt that thousands of perfectly viable numerator hits were backed out of rates this year due to fear of failing the audit. This was a tough year for both Compliance Auditors and Health Plans; the stakes have been raised. CMS is paying out (or not paying out) hundreds of millions of dollars in STAR Rating bonuses based largely on HEDIS® performance. The is more pressure on auditors to make sure that their audit work papers reflect a scrutiny that satisfies the NCQA and CMS that rates are valid and free of shenanigans. The convenience sample is not the only time auditors should give health plans feedback. Plans pay auditors for their services and can switch if auditors are not adding value. Have auditors review troublesome measures throughout the project. This way, plans can submit numerator lists with more confidence and less back tracking on hits due to nerves.
  3. Year-round partnerships with chart collection and abstraction vendors are more critical than ever. Points 1 and 2 above amount to very little if a plan and its vendor cannot get out of the gates fast. Both parties need to work together in the off-season to identify a network engagement strategy that will assure timely access to groups and physician offices. For example, identify special-handling groups that should be done first, EMR groups to which plans may be able to get access, or groups that may be open to block scheduling prior to the release of the samples. These are all worthwhile “off-season” activities that plans and vendors can collaborate on to ensure a fast launch in 2014.

What have you learned from the HEDIS® 2013 season?

About The Author

Reveleer is a healthcare-focused, technology-driven workflow, data, and analytics company that uses natural language processing (NLP) and artificial intelligence (AI) to empower health plans and risk-bearing providers with control over their Quality Improvement, Risk Adjustment, and Member Management programs. With one transformative solution, the Reveleer platform allows plans to independently execute and manage every aspect of enrollment, provider outreach, data retrieval, coding, abstraction, reporting, and submissions. Leveraging proprietary technology, robust data sets, and subject matter expertise, Reveleer provides complete record retrieval and review services, so health plans can confidently plan and execute programs that deliver more value and improved outcomes. To learn more about Reveleer, please visit Reveleer.com.