The HEDIS 2020 season is upon us and the countdown to submission has started. Every moment during this stretch is valuable and can ultimately impact your measure scores.

Cotiviti has compiled a list of mission-critical activities and best practices to help you meet all reporting requirements and timelines. We start with a quick review of the tasks you’ve likely completed by mid-January in preparation for a production run. If your organization lacks clarity on progress or is behind on these activities, this is where you’ll want to begin.

Part 1:  Regroup and game plan

  • Verify alignment on file specifications
  • Regroup internally on project and training plans
  • Complete test runs and troubleshoot

Part 2:  In the trenches

  • Complete your production run and prepare CAHPS® submission
  • Retrieve your records and start abstraction
  • Run an administrative data refresh

Part 3:  The home stretch

  • Submit your MRRV data
  • Don’t forget state submissions
  • Prepare for final submission

Part 1: Regroup and game plan (October–January)

Verify alignment on file specifications.

A project plan is a critical component of the test run process and should detail when you’ll have file mapping completed. Begin implementing changes to input files with the first version of software released (Cotiviti releases in mid-August). Starting early allows you to implement these changes in time to run measures and view any variances in the October timeframe. If a vendor supports your HEDIS reporting, ensure you have mapped your data to any required specifications to avoid integration issues. Have a conversation with your vendor about file layout to avoid data issues later in the season.

Regroup internally on project and training plans.

A formal kickoff attended by internal stakeholders and your supporting HEDIS vendor was likely held in October or November. It’s not a bad idea to regroup at the beginning of January to review roles, responsibilities, and progress on critical activities. You can also use this time to answer any lingering questions and look at the latest project timelines. Provide an update on scheduled training sessions which should include key team members such as analysts, medical record review managers, and those who may perform abstraction or over-reads. Use this training to review the timelines, specifications, and updates to the reporting software to ensure your team is comfortable and ready to hit the ground running.

Complete test runs and troubleshoot.

The most critical aspect of a test run is to validate data mapping as it will ultimately impact your rates. If there’s testing work that wasn’t completed at the end of 2019, make it a top priority now. Being proactive is instrumental to a successful HEDIS season. Benchmark your rates to the NCQA percentiles to identify any outliers that your auditors might flag. Pull a test sample and chase for your hybrid measures, and use it to validate location data and determine if location or provider data needs updating. The earlier you can pull a reliable sample/chase, the better. First movers have the advantage of making first contact with providers for records requests and receiving responses to those requests. If it’s the right strategy for your plan and you’re looking to be even more proactive, you can consider an early sample draw.

Overall, test run data errors will help refine your input data early, mitigating challenges when your focus needs to be on finalizing your submissions. Once the data is updated and corrected, your production run will more accurately identify members to chase for retrieval and abstraction efforts.

Part 2: In the trenches (February–May)

Complete your production run and prepare your CAHPS submission.

Using the updated data from your test runs, target a production run with a hybrid sample early as possible in the new year. The production run should include your production sample pull and chase logic. In general, the sooner you’re able to pull a provider sample and chase, the higher your likely rate of success in getting records back in a timely fashion. Ensure that your chase logic returns expected results. In addition to the production run, generate the extract to send to your CAHPS survey vendor. Make sure you know your vendor’s deadline and whether it requires any additional fields in the extract. If you are using a vendor for any reporting effort, make sure its measures are NCQA certified by February 15.

Retrieve your records and start abstraction.

Retrieval and abstraction process steps are typically underway by March, although earlier is always better. The retrieval process can be streamlined through location data cleanup. Capturing accurate addresses and provider information is essential for overall efficiency during the season. Prior to starting the abstraction process, the abstraction team (internal or third-party) needs to have up-to-date knowledge on hybrid measure data collection requirements and should have conducted inter-rater reliability testing. Make sure quality checks and over-read processes are in place to ensure the abstraction data is correctly entered throughout the season. This will help ensure you are ready for medical record review validation (MRRV) and successfully pass all measures.

Run an administrative data refresh.

An administrative data refresh will ensure that you process the claims and supplemental data received later in the measurement year, not those included in your initial production run. This step is typically completed in March or April (depending on your claims lag) to give you enough time to review and validate the results. Make sure your auditor approves all supplemental data by March 31.

Part 3: The home stretch (May–June)

Submit your MRRV data.

The MRRV process uses like-measure groupings to validate all hybrid abstraction. You need to send your auditor final numerator-compliant counts for all measures and exclusions by May 8.

Don’t forget state submissions.

Keeping track of state-based submission specifications and finalizing reporting details are critical yet often overlooked last steps in the annual process. Be sure that the review and validation of state measures are part of your overarching HEDIS project plan so you are not rushed during the state submission process. All states are different, so verify deadlines and requirements for any state submissions.

Prepare for final submission.

Being proactive at each stage of the HEDIS season is the surest path to success. You don’t want to submit in the final week and find yourself with critical issues up against a hard deadline. Routinely review the status of project tasks and be sure to remove any roadblocks that may prevent Interactive Data Submission System (IDSS) or Patient Level Data (PLD) submission by June 15. Utilize early PLD testing and IDSS uploads, especially before hybrid measures are locked, to review any errors or warnings in your submission that your auditors might question. Use the PLD balancing reports to ensure your IDSS values match your PLD values, or else your submission won’t be accepted. Work with your vendor and team to resolve any issues or questions you may have so that you can achieve plan lock by June 1.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).