The 10 most significant HEDIS challenges

Improving quality measures and HealthCare Effectiveness Data and Information Set (HEDIS®) scores is becoming increasingly important to improving Star ratings and bottom-line performance. But to boost HEDIS scores and gain competitive advantage, health plans must be aware of the challenges and the strategies necessary to meet them.

The 10 most significant HEDIS challenges and strategies:

  1. Find adequate time and resources. With additional dates added throughout the year for different audit requirements, there is more pressure on both time and resources. It’s important to ensure the right staff and resources are in place to manage increased demands.
  2. Stay motivated for year-round preparation. Once HEDIS submissions are complete for the year, review them for critical insight into the challenges and barriers you may encounter in the next. This will help you form a work plan for the upcoming year.
  3. Have a robust alternate plan. No matter how robust your preparation plan is, it’s a smart idea to have a “plan B” ready. This will help you be more flexible when needs arise — and ensure success, should changes become necessary.
  4. Conduct mock audits. There’s no such thing as too much preparation. Mock audits help to reduce potential pitfalls, lower the number of audit follow-up issues and requests, and reduce follow-up work.
  5. Maintain patient-level detail (PLD) accuracy. PLD errors typically occur at critical times, often requiring increased use of resources. Test early and often to improve accuracy, particularly if there is a contracted software vendor.
  6. Strategically plan for medical records review validation (MRRV). Meticulous and strategic planning and execution will help ensure success for MRRV. Bring in extra staff and provide additional training, as needed.
  7. Use administrative supplemental databases strategically. Ensure that any supplemental databases you employ are prioritized and approved, and have met primary source verification (PSV) audits.
  8. Build on the year’s experience. Leveraging your records from the previous year removes some of the guesswork for the next year’s HEDIS preparation.


  1. Invest in resources that increase agility. The proper tools and dashboards provide valuable line of sight into daily performance and progress toward goals. This can help you make priority calls and practical shifts during critical time.
  2. Keep up your momentum. HEDIS is a marathon, not a sprint — proper planning and robust resources can help you take it all in stride.

While there are significant challenges to improving HEDIS scores, the right strategies can help you manage and successfully meet them. We provide more in-depth discussion of these strategies here.


About the Author:

Mallory Van Horn, MPH, MBA
Sr. Director, Consulting, Optum

Mallory Van Horn leads the Quality consulting practice for Optum. She has 15 years of health care experience, focused on assessing, designing, implementing, and launching Quality Improvement and Quality Management and Performance business solutions for the payer and provider market.

Mallory’s area of expertise includes HEDIS® and Stars with a particular focus on clinical quality measurement and reporting, state regulatory clinical quality reporting requirements, and administrative data improvement strategies.

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