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Best Practices to Drive HEDIS Success in 2017

As the financial success of a health plan is so closely aligned with quality reporting, a year-round HEDIS process rooted in best practices is critical.

By Brian Drozdowicz of Verisk Health

- Achieving success requires plans to adhere to annual changes from the National Committee for Quality Assurance (NCQA) related to HEDIS measurement, reporting requirements, and timelines. In addition, health plans can better position themselves with effective pre-submission planning that streamlines the process.

HEDIS quality measures

Here is a checklist to help optimize the process and stay on track for HEDIS reporting in 2017:

Capture lessons learned from 2016

Although you may have just crossed the finish line from this year’s HEDIS season, assessing the successes and challenges of 2016 will drive better outcomes in 2017. Conduct a detailed review of work this season to inform planning and preparation for next season. Don’t forget to celebrate and share what has been completed—this was a big effort, and the team deserves acknowledgement.

Evaluate vendor support

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A thorough evaluation of the 2016 reporting process may reveal gaps in current submission efforts, as well as potential opportunities to team up with a vendor to improve scores and reduce administrative burden. Take time this summer and early fall to evaluate the end-to-end process, including any vendor services provided. If rates are below the benchmark, it may be time to shop for a new partner. Ideally, vendor changes or additions should be in place by October. If contracting with a new vendor, be sure it can manage an effective transition process, including data translation and rate reconciliation.

Examine the requirements for 2017

Staying ahead of changing HEDIS reporting requirements and timelines is critical for a well-managed process. Connect with auditors as soon as possible to better understand new requirements and validate the seasonal timeline. Review the new HEDIS specifications when they are released in July, and connect with your vendor for any input specification updates. Once the information is available, identify gaps in technology, processes, or staffing based on the assessment of this season’s work. Consider whether additional programs or technology can improve reporting next season. Initiate process steps to close gaps based on the assessment.   

Conduct provider outreach

The results from 2016 are powerful data points to place in providers’ hands, especially where P4P contracts are in place. Communicating aggregate results, as well as provider-specific rates, can help improve collaboration with providers to reduce care gaps. Sharing HEDIS data with providers can also improve medical record exchange frequency and efficiency, as providers will further value the importance of a smooth and complete exchange of information. Quality software can assist in sharing year-end or prospective rates with providers and can help them monitor progress and target patients proactively.

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Organize the team, and kick off the process

Planning for next year’s reporting effort is best facilitated through a formal kickoff meeting, especially if a HEDIS vendor is providing support. October is a great time to conduct this kickoff meeting and to introduce your vendor’s team to your internal team. Use this time to clarify roles, responsibilities, and expectations, address questions from the team, and communicate specific submission due dates and reporting requirements to your HEDIS vendor.

Connect HEDIS reporting to other quality reporting efforts

HEDIS measures are a foundation for many other quality metrics that a plan needs to report to various entities, including CMS Five-Star Quality ratings and state-specific reporting. Consider looking at all quality reporting requirements holistically. Identify the overlap in the datasets to achieve greater process efficiency, and focus limited resources on measures that will drive the strongest outcomes.

Align input file specifications

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A project plan is a critical component of the test run process and should detail when file mapping will be completed. Implement changes to the input file layout in the fall so that you can utilize first software releases to run measures and review any changes. If a vendor provides support for HEDIS reporting, ensure that data has been mapped to any required specifications to avoid integration issues.

Develop a training plan

Annual HEDIS training helps ensure all staff members are on the same page with timelines, NCQA requirements, software updates, and process changes. The fall months can be used for training, planning, and preparation work. Schedule training sessions for the winter months, and be sure to include key team members like analysts, medical record review managers, and any other stakeholders who may perform abstraction or over-reads. Use this training to review the timelines, specifications, and updates to the reporting software and ensure the team is comfortable and ready to hit the ground running.

Complete multiple test runs and track the results

Performing and validating test runs before January 1, 2017 allows time to assess variances, address gaps in the process, and coordinate with providers before it’s time to complete the formal production run. Benchmark your rates to the NCQA percentiles to identify any outliers that auditors might flag. Pulling a test sample and chart chase for hybrid measures can help validate location data and determine if location or provider data needs to be updated. Test run data errors will help refine software and input specifications early on, mitigating challenges when the focus should be on finalizing the submissions. Once the data is updated and corrected, the production run will more accurately identify members to chase for retrieval and abstraction efforts.

Complete your production run and prepare your CAHPS submission

Using the updated data from the test runs, target a production run as early as possible in the New Year. The production run should include the production sample pull and chase logic. Ensure that the chase logic returns expected results. Aside from an administrative refresh, this data should be ready to submit. In addition to the production run, generate the extract for member addresses to send to your CAHPS survey vendor. Make sure you know your vendor’s deadline and whether it requires any additional fields in the extract. If you are using a vendor for any reporting effort, make sure its measures are NCQA Certified by February 15, 2017.

Retrieve records, and start abstraction

Retrieval and abstraction process steps are typically under way by March. The retrieval process can be streamlined through a location data cleanup. Capturing accurate addresses and provider information is essential. Prior to starting the abstraction process, the abstraction team (internal or third party) needs to have up-to-date knowledge on hybrid measure data collection requirements and should have conducted inter-rater reliability testing. Make sure that quality checks and an over-read process are in place to ensure the abstraction data is correct.

Run an administrative data refresh

An administrative data refresh will ensure that any claims are processed and supplemental data received later in the measurement year that was not included in the initial production run. This step is typically completed in March or April (depending on your claims lag) to give enough time to review and validate the results.

Submit your MRRV data

The medical record review validation (MRRV) process uses like-measure groupings to validate all hybrid abstraction. Final numerator compliant counts for all measures and exclusions for MRRV need to be sent to the auditor by May 15, 2017.

Don’t forget state submissions

Keeping track of state-based submission specifications and finalizing reporting details are critical, yet often overlooked, last steps in the annual process. Be sure that the review and validation of state measures are part of the overarching HEDIS project plan so that the state submission process is not rushed. All states are different, so be sure to verify deadlines and requirements for any state submissions.

Prepare for final submission

Routinely review the status of project tasks and be sure to remove any roadblocks that may prevent Interactive Data Submission System (IDSS) and/or Patient Level Data (PLD) submission by June 15, 2017. Utilize early PLD testing and IDSS uploads, especially before hybrid measures are locked, to review any submission errors or warnings that auditors might question. Work with your vendor and team to resolve any questions you may have.

If you need help optimizing the process and hitting deadlines for HEDIS reporting, follow these steps to fine-tune your plan for 2017. Look back at the previous year for lessons learned, and then develop an updated plan for hitting critical reporting milestones in the upcoming year.

Brian Drozdowicz is the executive vice president of product management at Verisk Health.

Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement
• Why HEDIS Quality Measures Matter for Value-Based Care


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