Copy of hedis infographic


Continuing from Part 1 of our Prospective HEDIS blog series, let’s take a 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.

First, Prospective HEDIS allows a plan to create non-supplemental administrative data for reporting. 

Non-Standard Supplemental Data is data that is not received through structured electronic sources, typically it is data from a medical chart.  This is a critical area of value added though Prospective HEDIS.  Supplemental data is valuable in improving efficiency of data collection and delivers visibility into performance rates on an ongoing basis.  This is not only valuable in annual HEDIS reporting but also serves to improve the accuracy and credibility of Value Based reporting for your provider groups in these arrangements.

Another important improvement that can be driven from Prospective HEDIS action is provider and/member outreach on confirmed gaps in care related to HEDIS measures. 

The hope is that by performing chart review you will find evidence of the missing service, but often that is not the case, which creates an opportunity for additional outreach to close the gap.  HEDIS measures have very specific timeframes for services to be provided in order to be scored as compliant during the upcoming year’s HEDIS reporting.  It is important to be aware of each measure-specific timeframe, so that any additional outreach will result in numerator compliance as defined in the HEDIS Technical Specifications.

As discussed earlier, Prospective HEDIS work is generally population focused, it is often ongoing, and can involve a significant volume of chart review.  In order for Prospective HEDIS activities to produce meaningful results for your organization, you should expect to target large segments of members that could be included for reporting in HEDIS 2021.  It is unlikely that many of us have the time and resource capacity to perform chart review for all open gaps prospectively, therefore it’s important to prioritize measures with data, and target membership based on the likelihood your prospective chart review efforts will yield meaningful results.

  1. Create a timely, accurate and concise scorecard showing where your health plan stands in relation to its annual HEDIS® goals and ultimately its NCQA accreditation. 
  2. Select priority areas for improvement in consultation with the plan’s clinical leaders.
  3. Identify subpopulations of members with gaps in care, many of whom are also the plan’s rising-risk patients. 

Finally, in looking forward to the future of HEDIS reporting, it is very likely that the need for collecting supplemental data from non-standard sources will grow in importance.  NCQA has started on the journey to digital measures, with the potential of marginalizing or even eliminating hybrid review for annual HEDIS reporting, sometime in the future.  This fact further emphasizes the importance of having a Prospective HEDIS strategy in place.  Administrative data is, and will continue to be, a very relevant and informative data source and is one of the four major data categories for reporting from Electronic Clinical Data Systems (ECDS).   Creation of supplemental claims from non-standard data sources (medical charts) will be more important than ever to improve rates when data capture from standard administrative claims information is generally low.

Prospective HEDIS is a critical activity for continuous improvement of HEDIS and STARs performance both today and into the future.  Reveleer’s Prospective HEDIS and Gap Closure software is helping Health Plans across the country achieve better HEDIS performance and STARs ratings, and we can help your Plan implement a concurrent, Prospective HEDIS strategy.

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