HEDIS prospective - Blog image-2

Reveleer has been actively helping our customers perform Prospective HEDIS reviews for several years, and we have seen significant uptick in health plans that are making this activity a cornerstone of their HEDIS improvement plans.
During this time our customers have realized several important benefits through this work:
  1. Every event found in the chart related to a HEDIS measure that applies to a member, can be transformed into supplemental data.  You may be reviewing a male diabetic for an eye exam gap, and also find evidence of a BMI and recent FOBT, all of this information can be captured and used to enhance a health plans ability to report more accurate administrative rates for HEDIS and other quality reporting initiatives related to Value Based Care.
  2. By increasing HEDIS administrative rates, Plans have healthier starting points during reporting year HEDIS, fewer charts to chase during the compressed retrieval timeline and an ability to focus resources on other rate improvement activities during annual HEDIS collection.
  3. Once a chart has been reviewed for a specific gap, and the gap remains open, there is an opportunity to perform additional provider or member engagement to promote the closure of the gap through getting care. 
  4. Finally, a Plan can gain and maintain accurate and current provider demographic information by virtue of year-round network engagement, increasing the chances of more rapidly getting to the right person at the right location to retrieve charts or gain EMR access during the active HEDIS reporting season.
Prospective HEDIS -

A quick definition of how Prospective HEDIS differs from the routine HEDIS reporting we do each year between January and June: For most of us Reporting HEDIS is a requirement, not a voluntary activity.  Annual HEDIS reporting is intended to inform the public and regulatory agencies how effective our Health Plans are at delivering high quality care, on time in the correct setting.  This is done by looking back on the prior year and calculating results for some HEDIS measures according to NCQA Technical Measure Specification.  It's completely retrospective and for reporting purposes only. 

Prospective HEDIS looks forward, it is sometime referred to as Concurrent HEDIS, because you are looking to see if members are having the care that will be reported on Next HEDIS Reporting Season (2021) throughout current year.  Unlike regular (retrospective) HEDIS, Prospective HEDIS is not a mandated activity, but it is one that we believe is extremely vital to optimize HEDIS scores and performance on STARs ratings.

A few more important distinctions between Retrospective (Reporting Year) HEDIS and Prospective.  Whether we are talking about Retrospective HEDIS or Prospective HEDIS it is all about closing apparent gaps in care.  The hybrid chart review samples that we generate each year for HEDIS reporting are really nothing more than lists of members that did not have a claim or other administrative data that showed a service was provided during the time frame specified by the HEDIS Technical Specification.  Performing chart review on these samples allow health plans to boost their reported rates for a subset of HEDIS measures where we know that the administrative data is often incomplete or unreliable.  And again Retrospective HEDIS is purely for reporting purposes, what's done is done, there is no way to improve the rate if beyond finding acceptable chart documentation.

Prospective HEDIS is also about addressing apparent gaps in care as measured by HEDIS, but with a few meaningful distinctions:
  1. You are not limited to just measures that NCQA allows chart review for during annual HEDIS reporting.  Many of the measures that are scored using Administrative data only for Annual HEDIS reporting can be included in your prospective review.  This gives you a chance to find missing qualifying numerator events and exclusions for measures that you won't be able to leverage chart data for during annual HEDIS reporting. (e.g. Breast Cancer Screening).
  2. You are NOT limited to pursuing a small sample of members.  You can, and should, cast a much broader net.  Prospective HEDIS is about closing gaps throughout the year BEFORE it is time to report on success during Annual HEDIS Reporting.  For Prospective HEDIS to be successful a plan should target much larger segments of the population, not just samples.  The more gaps you close during the year for members that could be in next year's HEDIS sample for given measure, the better your reported rates will be next year. 
  3. You can convert data found in the chart during prospective chart abstraction into a supplemental claim that will be treated as administrative data for the upcoming reporting year.
  4. Finally, and perhaps most importantly, after you have completed abstracting a chart looking to find missing documentation to close a gap, and you find nothing in the chart that indicates the care was appropriately provided - YOU CAN STILL do something about it.  You can conduct additional outreach to members and/or providers to get that individual in to get the recommended care before the end of the measurement year.

Don't miss part 2 of the Prospective HEDIS blog, where we take a closer look at two important ways that conducting Prospective HEDIS can improve the care a Health Plan’s members receive and the scores that are reported for HEDIS each year.

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.