What is HEDIS?

Challenges of Meeting HEDIS ComplianceMeasuring the quality of patient care delivered has become paramount and edged out the former fee-for-service payment system. The Healthcare Effectiveness Data Information Set (HEDIS) is a tool developed by the National Committee on Quality Assurance (NCQA) to evaluate the performance of health plans on the quality of care and services provided to their members. HEDIS is used by more than 90 percent of America’s managed care health plans to measure performance on important dimensions of care and service.

HEDIS 2015 included 83 measures across five domains of care. To determine the measures, a team of health care experts review the health plan’s structure and operations against NCQA’s standards that target attributes such as patient safety, availability of care, effectiveness of care, experience of care, and other important areas of service. It helps evaluate the cost of care, quality of care, and value rendered to patients.

How is HEDIS used?

Health plans seeking NCQA accreditation use HEDIS to measure performance on important dimensions of care and service. The Centers for Medicare & Medicaid Services (CMS) has adopted many HEDIS measures and includes these in their Medicare Advantage Star ratings. State agencies and other organizations also set performance guarantees under contract for health plans based on specific HEDIS measures. Consumers can compare plans that use HEDIS and choose one that supports accountability and quality improvement.

HEDIS Data and Documentation Reporting Regulations

Health plans that want to obtain NCQA accreditation need to collect data on patient care, organize it into specific measures defined by HEDIS, and verify if specific criteria for HEDIS measures have been satisfied. Insurance companies collect HEDIS data through:

  • Administrative data from claims
  • Hybrid data from claims and medical record reviews
  • Survey data from member and provider surveys

Claims and encounter data cannot provide a complete picture of all services rendered. Some HEDIS measures require actual documentation to support the measure for compliance. Documentation of all care in the medical records and accurate medical coding in claims is crucial.  HEDIS medical record review (MRR) ensures that complete and accurate data is collected and reflects the care patients receive from their providers. MRR measures and evaluates medical record documentation of care as well as timeliness and quality of service.

Before publicly reporting their HEDIS data, each Managed Care Organization (MCO) must go through an NCQA Compliance Audit to ensure that MRR is accurate and reliable. They must also meet HEDIS data collection deadlines, which end in late May for all health care plans. Medical records have to be made available on the date of the onsite review, or in the case of fax/mail requests, by the date requested. Medical record reviews may require data collection on services obtained over multiple years.

Professional Services to Ensure HEDIS Compliance

Increase in the volume of enrollees and the stringent rules for HEDIS compliance are among the many challenges that contracted insurers face. Relying on a medical coding and billing company that provides comprehensive support services to help them ensure HEDIS compliance is feasible option. These specialized services would cover all phases of the HEDIS process such as

  • Data collection
  • Medical record abstraction
  • Medical record retrieval
  • Medical record review
  • Detailed audit of records
  • Real-time reporting
  • NCQA submission

The staff in these companies would be well-informed about the description and specifications for frequently changing NCQA hybrid measures. They have a team of accredited medical coders that are knowledgeable about CPT codes and ICD-10 coding, which is necessary for data optimization. Such support is crucial to ensure HEDIS compliance and meet data submission deadlines.

Outsourcing companies also help physicians improve their scores for HEDIS measures and receive appropriate reimbursement and financial incentives by

  • Ensuring accurate HEDIS documentation
  • Submitting claims with codes specific to the HEDIS measures
  • Responding promptly to the request for medical record documentation by payers

For both payers and providers, meeting NCQA’s stringent performance evaluation requirements on required HEDIS measures is much easier with support from a reliable HIPAA-compliant medical coding company.