Skip to main content
two people sitting at a desk working on reports with a laptop and tablet

How to succeed during HEDIS® Reporting Season

HEDIS®, or Healthcare Effectiveness Data and Information Sets, are widely used in setting performance measures in healthcare where improvements can make a meaningful difference in people’s lives.

The National Committee prepares HEDIS measures for Quality Assurance. They include 90 metrics that flow across six domains, gathering and analyzing patient care information from payers and providers based on industry best practices.

This blog covers how to succeed during the HEDIS reporting season with tips any health plan reporting team can use.

Use and understand your data

Ensure you have data from all required sources by conducting an audit or evaluating your data streams. Your results are only as good as your data, so review the NCQA (National Committee for Quality Assurance) Technical or State Measure Specifications.

This helps ensure all required data elements transition from your data source to meet HEDIS measure specifications. Conduct frequency reports to ensure you have included all pertinent data for the measurement period. Look for gaps in dates of service. Also, check for data inconsistencies or non-standard coding practices, and if found, work with an auditor on using non-standard codes for rate production.

Streamline your MRR process

Start to streamline your MRR, or Medical Record Review, by identifying physician locations that maintain your members’ medical record information. Also, identify physicians who should be excluded from this process.

The process must include a test of hybrid pursuit logic and an assessment of whether you can collect data using EHR (electronic health record) interoperability, or obtain EHR access for abstractors. In addition, ensure that all physician contact information is up to date, including fax numbers, telephone numbers, and addresses.

Patients seek high Star Ratings

Only one in five patients use the CMS (Centers for Medicare & Medicaid Services) Star Ratings when making healthcare decisions, but they will more frequently choose plans with high ratings.

This trend is expected to increase as more patients become empowered in selecting their healthcare plans. In addition, as more people become comfortable with technology, they will continue seeking improved patient experiences.

Consider introducing digital tools to improve member communication and use the digital data collected to inform quality measure performance strategies and goals.

It is never too early to prepare

As you prepare for quality data submission, launch your quality strategy to face the obstacles in the coming year. There is steep competition among health plans, so stay current on new data requirements.

Incorporate critical dates into your HEDIS timeline and run baseline rates and benchmarks against historical rates. Engage an auditor to generate rate runs, identify non-compliant members, and use outreach when needed.

Develop an early HEDIS roadmap and project plan – audit, review, and update all policies and procedures as warranted.

Telehealth and other changes affecting HEDIS measures

During the COVID-19 pandemic, the telehealth landscape changed dramatically. It expanded to support the delivery of acute, chronic, primary, and specialty care. For this reason, telehealth visits and their related claims may contribute to HEDIS measurable quality outcomes.

However, the U.S. Department of Health and Human Services took a range of administrative steps to expedite the adoption and awareness of telehealth during the COVID-19 pandemic. Many of the telehealth flexibilities are temporary and will lapse at the end of the COVID-19 public health emergency.

Until then, code telehealth claims just as if the visit took place in an office.

Ensure success

Leverage your opportunities for improvement by looking at the last issue logs to define best practices. Next, include necessary enhancements by referencing your prior year’s roadmap. Finally, identify any changes in internal processes that could impact your upcoming HEDIS season.

Engaging with an auditor sooner is a terrific way to prepare for an audit and measure production. Your organization will be in a great position to head into the next HEDIS season by ensuring you have effective strategies, comprehensive analytics, and robust data sets to guide you through the process.

Excellent HEDIS scores will more likely lead new members to look at your health plan. So, stay ahead of the curve on future quality outcomes improvement.

Checklist for success

    • Work with your auditor to understand deliverables, timelines, and requirements
    • Implement incentives to reap the benefits of your HEDIS measures
    • Ensure you are up to date on policies and procedures for identifying data gaps, then address data inconsistencies or incomplete data
    • Update all provider information early
    • Test and conduct quality assurance thoroughly to remain above minimum requirements
    • Know the regulations to understand reporting requirements
    • Identify any incomplete data sources
    • Stay current on new data requirements

HEDIS measures and HEDIS scores can improve outcomes when serving new and existing patients, so attention to the metrics used in these measures and scores can help ensure future success.

To learn how Inovalon can support you during HEDIS reporting season, discover our Converged Quality solution.

“HEDIS Hybrid Measure Medical Record Review (MRR)”; Agency of Human Services Department of Vermont Health Access;

“Telehealth policy changes after the COVID-19 public health emergency”; U.S. Department of Health and Human Services;

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Inovalon and design® and Inovalon® are trademarks of Inovalon, Inc.

By Inovalon