Four Tough Questions About HEDIS Review in 2018

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.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Related Stories

Knowing the Score: MIPS

Knowing the Score: MIPS

EDITOR’S NOTE: Medicare’s legacy quality reporting programs were consolidated and streamlined into the Merit-Based Incentive Payment System, known as “MIPS.”  The Merit-Based Incentive Payment System

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Hospital staff continue to grapple with the complexities of Medicare notices.  In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, will present the latest requirements for preparation and delivery of CMS-mandated forms, including the Advance Beneficiary Notice (ABN), Hospital-Issued Notices of Noncoverage (HINNs), Important Message from Medicare (IMM) and Medicare Outpatient Observation Notice (MOON), and practical solutions through foolproof workflows and compliance auditing.

January 25, 2024
OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

Dive into the complexities of Obstetrics and Gynecology coding, addressing challenges from antepartum to postpartum care. Learn to decode intricate guidelines, tackle claim denials, and safeguard your practice’s financial health. Uncover the secrets to compliant coding, reducing errors, and optimizing reimbursement. With practical exercises and expert insights, this webcast empowers coders, auditors, and healthcare professionals to elevate their OBGYN coding prowess.

February 28, 2024
Unlocking Clinical Documentation Excellence: Empowering CDISs & Coders

Unlocking Clinical Documentation Excellence: How to Engage the Provider

Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.

December 14, 2023
Coding for Spinal Procedures: A 2-Part Webcast Series

Coding for Spinal Procedures: A 2-Part Webcast Series

This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.

October 26, 2023

Trending News

It’s Heart Month! Use code HEART24 at checkout to receive 20% off your cardiology products. Click here to view our suite of Cardiology products!