HEDIS® Season is the Reason: Make Year-round Preparation Part of Your Strategy

HEDIS® Season is the Reason: Make Year-round Preparation Part of Your Strategy

By Vandna Pandita, Vice President, Client Engagement & Product Operations

Fall, winter and then HEDIS®.  Yes, HEDIS.  It is its own season for many of us that work in healthcare.  However, the images of HEDIS season are quite different from other seasons. It is not defined by the temperature, the color of the leaves or the many holiday parties that we measure our days by.  It is the season of claims data, supplemental data sources, medical records, audit onsites and over-reads.  Lots and lots of over-reads.

The Healthcare Effectiveness Data and Information Set (HEDIS) was designed back in the early 1990’s by a coalition of employers, plans and the National Committee for Quality Assurance (NCQA®) to provide a consistent, measurable process for consumers of healthcare to assess health plan performance.  Since its inception, HEDIS has become one of the leading measurement sets of plan performance, used by direct consumers, as well as state and federal governments.

HEDIS is no longer considered to be a seasonal event.  Organizations commit resources year-round to manage data, assess activity, collect records and so on, all focused on higher reportable rates and improved member outcomes.  As you consider the upcoming HEDIS 2018 season, what are you most concerned about?  What are some of your greatest challenges?

If anxiety is kicking in, don’t let it.  It may seem late, but you still have the opportunity to ensure a successful reporting year.  We all know that HEDIS is built upon data.  If you haven’t already started processing your rates, you still have time to assess and scrub data.  Most importantly, spend some time confirming that you have full and comprehensive data to represent the measurement years relevant to your product line/reportable measures.

If you work with an IT or data team to extract the data set from an internal data warehouse, ensure you’ve confirmed that all required fields are included? Coordinate with your data team to do a spot check for the following data criteria:

  • If your system captures more than 10 diagnosis codes, are all codes included?
  • Are revenue codes included? Over the years, I have seen numerous data sets where the revenue codes were excluded upon extract, which created a significant negative impact on the reportability of measures such as Follow Up After Hospitalization for Mental Illness (FUH).
  • If you operate a Special Needs Plan, ensure that your data is appropriately aligned for reporting within its H contract, as well as Plan Benefit Package
  • Guarantee member enrollment spans should fall within your HEDIS reporting software’s criteria – many have limits on when an enrollment span can end so, be sure to check the file specifications.

Another, and in some ways most critical review of your data, is going to be scrubbing your provider data.  This provider data is key to minimize provider abrasion, maximize retrieval rates and will save your team a lot of time sorting it out later in the project when you won’t have the time or resources to do so effectively.  If you are working with a vendor to outreach and retrieve medical records for abstraction, having accurate provider data is critical as these resources are often less familiar with your provider network than your internal teams.  Next, prior to launching your chart chase project, review provider locations and addresses confirming as best as, and as clearly as possible, that you are sharing physical locations and that there are no PO Box addresses or addresses of billing companies rather than the provider’s physical address.

Finally, filter and review your provider type designations as well, keeping in mind that it’s better to remove inappropriate specialties such as Podiatrists, Ambulance Providers, Pathologists and so on.

While, the first month of HEDIS season is here and almost gone there is still time to adequately prepare for success.  Focus on the immediate goals — extract and share data with your software vendor, ensure that you get your CAHPS® sample frame to your auditor and survey vendor by the deadline, and get ready to launch!

Do you have a HEDIS best practices experience you would like to share? Contact me at  I am happy to discuss your HEDIS experiences and needs.

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