HEDIS season preparation: Are you confident in your HEDIS retrieval chase logic?

HEDIS Medical Record Review season is right around the corner. Once a production chase file is dropped, it can be difficult to make changes. Every active field day matters, so in this post we’ll discuss maximizing your time in the field via proactively addressing your chase file. Here are some steps to consider taking.

Execute a mock run with current-year chase logic. Conducting a mock run is essential to validating that your chase logic is working as expected. If it’s not, now is the time to fine-tune it.

Examples of what to evaluate when setting chase logic:

  • What chase logic was effective in previous seasons? Make efforts to retire or refine rules that did not work well for your organization last season.
  • Seek input from your auditor and/or vendor. Independent third parties who are familiar with your data likely have recommendations based on what they are seeing in the industry.
  • Evaluating how you set your primary care provider (PCP) flag. For example, if you are reporting a Point of Service (POS) plan, define logic to attribute a PCP to the member. Pro tip: It’s useful to pre-define tie-breakers for instances where two providers were seen an equal amount of time.

Analyze the results of your mock run:

Evaluate your chase volume.

  • Any large spikes or decreases from prior year?
  • Are your large provider groups represented?
  • Are all measures you are reporting as hybrid represented?

Consider which specialties are being triggered by your chase logic.

  • Look at which specialties you are going to for each measure/measure numerator. Are the specialties what you would expect?
  • Is your chase logic too broad?

– For example, you’re not likely to pick up CDC Eye compliance at a gastroenterologist visit. If you see this, your logic is too broad. Refine your logic to ensure more efficient efforts.

-Frequently health plans set wide logic like “Give me every visit from every provider.” Their goal is to ensure no stone is left unturned. However, use this logic as a last effort. Chase your high-priority logic first.

Review for offices that have a history of being non-responsive. When possible, engage your Provider Services early and pre-schedule the offices that are hard to get into.

Initiate a second mock run using final year’s data. As a best practice, it is useful to conduct an additional mock run in January using your final data set. This allows you to make any final tweaks and account for problems you identified in the first test run.

In our next post, we’ll review additional strategies to support a smooth and successful HEDIS Medical Record Review season.

Learn more about improving performance on quality measures

About the Author:

Cybil Fry Headshot_Option 1.jpg

As director of Clinical and Quality Solutions at Optum, Cybil Fry partners with health plans to improve their HEDIS scores. Prior to joining Optum, Cybil spent significant time leading HEDIS efforts for health plans. She first worked in data analytics with a focus on accreditation. She later led HEDIS/Stars reporting and initiatives. She had the pleasure of conducting end-to-end HEDIS across all lines of business and accomplishing year-over-year improvements. Cybil also led a team that consistently met all Medicare Stars goals each year. After achieving her HEDIS goals as a health plan employee, Cybil moved to Optum to help clients achieve their HEDIS and Stars goals. She recognizes “the purpose of quality reporting is quality improvement,” and focuses her sights on developing innovative means to project and improve HEDIS outcomes.

Cybil holds a BA in Information Systems and has an extensive background in trend analysis.

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