Happy Halloween! – What’s Scarier than Not being Ready for HEDIS 2018?

Written by Aaron Lebovitz, President.
Contact him at 1.800.974.4828 ext 102, or aaron@carenational.com

Since this weekend is Halloween, I thought we should ask: What’s scarier than not being ready for HEDIS season? How about providing high quality service and not being able to prove it through your data reporting? The ghostly ghouls and goblins of HEDIS deadlines creep closer daily, so we wanted to start with the first step in the process, Data Validation.

As the 2018 HEDIS season approaches, CareNational is dedicating a series of blogs to help health plans. Since we are experts in providing top-tier talent, but not in actually doing Quality Improvement or HEDIS functions, we are tapping into the extensive knowledge of our candidates using an ‘Ask the Expert’ format.

This segment comes from La’ Chanda Plummer, a highly qualified and experienced HEDIS Program Manager and Quality Improvement leader that we placed at a medium sized health plan in the Pacific Northwest recently. It was her job to see that this growing plan achieved NCQA accreditation and improved HEDIS Scores.  Under her direction, that health plan improved their Medicare Stars Ratings by 1.5 Stars in just 1 season!

She explained to us that before we can even discuss NCQA Accreditation, the first level is the compliance audit. You have to show NCQA that your organization has the ability to accurately reflect data. Are your systems compliant? Do they follow the NCQA blueprint? Health organizations can purchase an NCQA certified system, or they can use a proprietary system that mimics this type of system in reporting.

What are the upsides and downsides of each? With an NCQA certified system you are able to omit many sections in the compliance outline because the vendor will fulfill those. Whereas, when your system does these things internally, you must have your source code validated. You have to be very mindful of the details because there are rules of engagement when validating your data. After a certain number of failures in your validation, an auditor can shut down your compliance audit.

Either way, your organization must work backwards and do cross validation comparing what your system is reporting against what your claims reflect. This is done by pulling out a sample of 10 of the metrics that you are going to report, based on the priority measures established by the governing state. Pull a sample of 10 of the excluded population, your denominator, your eligible, your non-participating members and your participating members. Then follow that member from the time you got the claim back to when they got the service. Is there a problem with your data? Are there members that actually got the service but you can’t prove it?

You’ll need to walk that data further back. Look and see how your logic is being conveyed. Who is programming that logic? Is there a comma in there by accident? Are they using date of admission instead of date of service? These are key components that will either give you too much credit or cost you credit when you really deserve it. A lot of plans are really doing great work but they can’t accurately prove it because of small errors in the data that negatively impact them.

We hope that the checklist available above will be useful when you evaluate this season, and when you consider what staffing vendor to partner with for the HEDIS hiring season.

Special thanks to La’ Chanda Plummer for providing all this great, detailed information. She is a highly credentialed healthcare industry professional with demonstrated success in leading quality analysis, project oversight and compliance management for high profile employers in the clinical and insurance sector. She is an expert in all things related to Quality Management, NCQA, and HEDIS.

Listen to the full Podcast HERE.
Written by Aaron Lebovitz, the President of CareNational. For more information on how we can assist your organization with all your HEDIS staffing needs, reach out to one of CareNational’s founding partners!
Contact him at 1.800.974.4828 ext 102, or email him at aaron@carenational.com