For many years the Medical Record Review Validation audit followed a relatively straight forward, tried and true process. At the beginning of the season, plans learned what measures would be selected for review knowing that new ones would be added only if the compliance auditor thought there was a potential issue across the core group. Plans would review a specified number of charts within the core measure groups at about the half-way point of the retrieval process.  If problems were detected with the way a measure was being abstracted, the plan had time to take corrective action and get re-assessed.  Otherwise, if everything looked good, the measure passed and the charts would be filed away, never to be seen again.  That’s an overly simplistic but you get the point.  

As healthcare reform continues to build steam and the financial stakes around HEDIS® performance rise so too has the importance of the medical record review validation process.  In recent years, auditors revealed the measures that would be selected for audit on May 1st, just fifteen days before the deadline for abstraction completion.  In 2016 the bar is raised again and the mandate timeline is further compressed:

  • Plans stop abstracting by May 16th
  • Auditors will select measures and samples by May 18th
  • Plans submit their list of hits, medical records, and abstracts by May 23rd
  • MRRV and corrective actions completed by June 8th

The net effect is that all hybrid measures are on the table for MRRV unless NCQA has indicated they are not eligible.  HDVI is helping our clients stay prepared with our MRRV Wizard and Audit Prep tool.  With Audit Prep, the client has 100% visibility to numerator hits and exclusions for all measures for the entire project, and the ability to quickly flag and resolve any concerns when it comes to supporting documentation. 

This year, more than ever, it will be essential for health plans and abstraction vendors to work collaboratively to ensure success in what looks like a 100% overread scenario. 

HEDIS Best Practices

About The Author

Reveleer is a healthcare software and services company that empowers payers in all lines of business to take control over their risk adjustment and quality improvement programs. The Reveleer platform enables payers to independently execute and manage every aspect of provider outreach, retrieval, coding, abstraction and reporting – all under one single platform. Leveraging its technology, proprietary data sets, and subject matter expertise, Reveleer also assists payers with full record retrieval and review services to support financial performance and improved member outcomes.