What will you do differently this HEDIS® season?

Speaking from experience

With limited resources during the short HEDIS season, health plans must make quick decisions to prioritize the number of medical records to retrieve, abstract and over read to meet their goals. One year when I was at a health plan, we were at the end of the HEDIS season. We were two passing members’ short of meeting our four-star target for a particular measure. By having a plan to address high-value charts at the end of the season, we were able to identify the necessary members and achieve our four-star goal. HEDIS preparation is a continuous, all-year-long exercise. Begin preparing now to avoid the end-of-season “HEDIS crunch”.

Be proactive now rather than reactive later

The beginning of the year is the time to be sure you have the tools and processes in place so you can close the HEDIS season successfully.

At the beginning of the year, much of your emphasis should be on core HEDIS activities such as:

  • Evaluating the quality of your provider data to maximize chart return rates
  • Deciding strategically and realistically on measures to focus on for retrieval and abstraction
  • Securing an auditor

Keep the momentum going throughout the HEDIS season

As the year progresses, core HEDIS activities and standard processes will continue. However, there are other activities you can do to maximize HEDIS season success.

Following is a typical timeline and checklist to help you start planning and preparing processes:

Timing Activity What to consider
End of HEDIS season through November
  • HEDIS medical record retrieval
  • Abstraction staffing
  • Determine staffing requirements
    • Is your abstraction staff trained, ready and in place?
  • Determine timing requirements
  • Will you have an internal/external mix?
  • Do you have a vendor identified? (if not doing internally)
  • Do you have separate retrieval and abstraction teams?
  • How much to budget?
October to January Training and staffing needs
  • What measures will you abstract from 2018?
  • Do you have a comprehensive understanding of technical specifications across functional areas and technical specification changes?
  • Once trained, are the subject matter experts assigned based on their measure strength?
  • Can you test the abilities of your abstractors effectively?
  • Are inter-rater reliability (IRR) testing and methods in place?
  • Are budgets in place?
February to May Reporting
  • Were you able to track and trend abstractors?
  • Was your IRR testing effective and accurate? If not, did some abstractions slip through the cracks?
  • Did you address your abstraction concerns during training?
  • Do you have executive dashboards necessary for oversight of HEDIS quality operations?

Set up an end-of-year measure SWOT team now

Another thing you can do now is to set up a SWOT (strengths, weaknesses, opportunities and threats) team. This group will be laser-focused on high-value charts at the end of the year.

To build a SWOT team, choose the “best of the breed.” These elite SMEs should have a keen understanding of the end-to-end process, to focus on specific charts only. Following are some attributes to look for in potential SWOT team members:

  • Knows specific markets really well
  • Excellent knowledge of measures and technical specifications, including hybrid measures and requirements for exclusions
  • Knows the data in detail
  • Exceptional at chart retrieval

The time to deploy your SWOT team will be as soon as you have the data to provide insight into where your plan is trending from a Star perspective. This is typically during the last six weeks of HEDIS season. SWOT teams are highly qualified people, so they can recommend what to do at the end of the year. For example, they can determine when to execute on outstanding charts. If there are members in your oversample that may be passes, they can oversample members in a specific order. If there are exclusions, they can determine how many to retrieve.

Three things to remember

The process to be prepared for HEDIS will be ever evolving. At the end of the HEDIS season, it’s good to have a “lessons learned” session to discuss what worked well and the opportunities for improvement. Once these areas are identified, amend your process. Here are few takeaways for you to consider:

  1. HEDIS preparation is a marathon, not a sprint.
  2. In the beginning of the season, focus on chart volume. Towards the end of the season, it’s more about value than volume.
  3. Set up a SWOT team to focus on targeted chart abstraction to achieve maximum performance.

See the latest advancements Optum is making in quality innovation. Visit optum.com/quality.

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

About the Author: 

brandontaylorheadshotBrandon Taylor, JD, MBA
Director of Risk, Clinical and Quality Solutions

Brandon Taylor is responsible for growth and strategy of risk and quality solutions at Optum. His expertise includes HEDIS, risk adjustment and Star Rating  strategy, health care interoperability, health law, population health management and business transformation. Brandon was instrumental in assisting the first publicly traded national plan to earn a five-star rating.


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