January 25, 2018

Four Tough Questions About HEDIS Review in 2018

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Best practices are described for eliminating redundancies and easing workloads during the HEDIS season now underway. 

Healthcare Effectiveness Data and Information Set (HEDIS) reviews are conducted by health plans and government payers every year from January to mid-May.

With the official 2018 HEDIS review season now in full swing, this article seeks to answer four tough questions about these reviews and suggests best practices to follow as hospitals prepare their teams.

What is a HEDIS review, and why are they so important to payers?

Payers participate in HEDIS reviews to improve their Medicare Advantage plan quality measurements, which are called Star Ratings. The Star Ratings system was developed by the Centers for Medicare & Medicaid Services (CMS) to rate health plan performance for Medicare Advantage programs and Medicare risk adjustment initiatives. HEDIS review measures are one component of the Star Ratings program. Customer satisfaction, operational performance, and pharmacy measures also contribute to a payer’s overall rating.

Data is derived from medical record reviews and submitted to third-party vendors that compile and submit information to National Committee for Quality Assurance (NCQA) by the May deadline. NCQA then determines and publishes the annual STAR ratings, which are also published annually on the CMS website to inform patients and the entire healthcare industry about plan performance.

It is important to note that a HEDIS review, as part of the Star Ratings program, can also benefit providers. The ratings give hospitals and health systems a view into each plan’s effectiveness and quality. This information becomes increasingly valuable to providers during payer contract negotiations. Plans that perform well ask for higher rates during contract review cycles, while those that underperform are contracted at lower rates.

 Which quality measures are being targeted for HEDIS review?

The 2018 NCQA’s  quality measures for HEDIS were published in autumn 2017. This summary table of measures, product lines, and changes is the best source for hospitals and health systems to review prior to each HEDIS review season. Equipped with the knowledge of which measures will be retired and which will be new for the coming year, providers should contact their contracted commercial health plans and government payers to discuss expected volumes of records to be reviewed and payment for health information management (HIM) efforts to compile the cases.

 What are the implications of HEDIS review on providers?

Based on MRO’s past experience in fulfilling medical record requests for HEDIS reviews, we predict a dramatic increase in volume for 2018. Of all the release of information (ROI) requests processed by MRO nationally in 2017, the number of HEDIS review requests rose 2 to 3 percent over 2016.

Greater volumes of record requests for HEDIS reviews impact departmental workload and operational costs in health information management (HIM) and the business office since these staff are responsible for the release of medical records. Knowing the approximate number of HEDIS record requests that will be received is a critical step to determine the necessary resources required, to ramp up staffing, and to ensure prompt response to HEDIS reviewers.

To offset these costs and spikes in medical record release volumes, many organizations proactively engage outsourced ROI vendors to assist. Another best practice is to ask government payers and commercial health plans to compensate for costs incurred during HEDIS reviews. Providers (or their designated ROI vendors) can invoice payers and plans for the time required to fulfill HEDIS requests, with payment ranging from $25 to $50 per patient record.

 How can we reduce payer-provider abrasion during the HEDIS review season?

The best way to minimize payer conflicts during the HEDIS review season is through proactive communication. A proactive strategy benefits all parties involved, payers and providers alike, while also reducing operational costs, eliminating redundancies, and easing workloads. Here are three best practices to consider:

  • Build stronger relationships with payers and health plans to better manage the surge in medical release of information.
  • Ask your ROI vendor to work directly with health plans or government payers to coordinate disclosure management instead of using internal staff or engaging a third-party vendor.
  • Consider electronic transfer of patient information and data with payers wherever possible to further reduce expenses and expedite the HEDIS process.

By focusing on payer communication and remaining aware of which quality measures apply, hospitals and health systems can reduce operational costs and improve compliance with payer requests throughout the 2018 HEDIS review season.

Greg Ford

In his role as director of requester relations and receivables administration for MRO, Greg Ford serves as a liaison between MRO’s healthcare provider clients and payers requesting large volumes of medical records for purposes of post-payment audits, as well as HEDIS and risk adjustment reviews. He oversees payer audit and review projects end-to-end, from educating and supporting clients on proper billing practices and procedural obligations to streamlining processes to ensure timely delivery of medical documentation to the requesting payers. Prior to joining MRO, Ford worked as director of operations and sales at ARC Document Solutions for 15 years. He received his B.A. from Delaware Valley University.

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