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How to Optimize the HEDIS® “Off-Season:” 4 Strategies to Act on Now


October 03, 2019

cotiviti headshotBy Branka Sustic, Cotiviti

The first six months of the year will always be the toughest for your quality department. But by implementing a truly year-round, proactive quality improvement strategy that cuts across all measure sets, health plans can achieve better results, both during the HEDIS® season and beyond. And over time, once you have established a successful routine, this can be accomplished with less busywork and more strategic thinking.

Quality improvement simply needs to be year-round and comprehensive for health plans of all sizes. Faced with a growing number of regulatory requirements, the increasing role of quality in how payers compensate providers (and how payers themselves are reimbursed), and a consumer population that has a wealth of options for researching health plans, there is no true “off-season” anymore.

Here are four strategies to drive success in 2020 and beyond for your organization.

    1.  Bring your internal teams and external partners together to work out the details for your monthly proactive runs.  

There’s no question that leading health plans are performing proactive runs on a monthly basis. In fact, Cotiviti has seen a 50 percent increase in the number of proactive runs we’ve performed for clients in 2019 year to date. But plans need a documented strategy before implementing this approach. Major questions to ask include:

  • Do you have enough staff to run and validate measures in parallel to HEDIS submission? If not, what resources will be required? Cotiviti has worked with many clients who began with as few as three full-time quality employees but have expanded to eight or more.
  • What are the important measures for your plan, and how will you prioritize them? Form a cross-functional group that includes care managers, pharmacists, and your provider relations department to determine where you can achieve the most significant gains or “quick wins” for the smallest investment of resources. Criteria for prioritizing measures include weight (primarily for Star Ratings), financial incentive (for state-based measures), or by NCQA’s benchmarks.
  • How will you handle off-cycle measures such as Osteoporosis Testing and Management in Older Women (OMW) or Antidepressant Medication Management (AMM)? Consider rolling 12-month runs to better detect gaps in these measures. Age-based measures can also be run in a rolling 12-month cycle so plans can see which members are aging into the measure earlier to start prevention efforts for closing those gaps.

    2.  Get actionable data from your reporting vendor to close care gaps through member outreach.

Dig into member-level data to identify non-compliant members, looking across several measures to identify patterns that may apply to other members. Ask your vendor to provide actionable reporting to simplify this process as much as possible. For example:

  • “Point-in-time” reporting indicating adherence for specific measures to inform whether the member will reach the measure’s adherence rate for full compliance, especially for important Part D adherence Star Ratings measures.
  • Member visit patterns so that you can better communicate with members on their own timeframes. For example, knowing which members will visit their doctor in September helps you know when to send them a reminder card.
  • Proxy survey measures to assist with CAHPS® survey and HOS scores to identify which members may need an additional care plan with their providers.

Leverage social determinants of health data to know which members might need additional benefits to get them to their doctor on time. For example, a rideshare benefit, mobile health clinic, or in-home visit could be crucial to close gaps in care for those without adequate access to transportation. Keep in mind the member’s preferred communication channel—younger members would generally rather receive a text than a phone call, for example—and offer incentives such as gift cards for those who participate in screenings or testing.

    3. Take a data-driven approach to provider outreach.  

Develop dashboard-style quality reports to share with providers to offer clear, transparent insight into how they rank against their peers and motivate improvement. At the same time, be sure to avoid information overload so that providers don’t ignore your efforts. For example, one large payer shares provider quality reports via a web portal, offering the following components:

  • Comprehensive care gap views on a practice level
  • Robust measures list
  • Color-coded measure adherence charts for both Medicare and non-Medicare populations
  • Detailed member level information provided in Excel format to allow filter and sort capabilities

The reports comprise both summary-level data covering a 12-month rolling timeframe as well as detailed data listing specific members with open care gaps, including both current and prospective gaps for the remainder of the calendar year.

The health plan’s manager of healthcare data operations shared a recent success story. “To improve our results for the OMW measure, our goal was to identify Medicare Advantage members with recent fractures and inform their primary care providers,” he explained. “But to support this, our reporting needed to be built from the ground up using claims data. It also needed to be as timely and actionable as possible to fit within the six-month post-fracture window for closing this gap.”

“We custom-built a SAS program that searches our claims database for recent fractures, gap closures, and exclusionary criteria, and summarizes this information for each member,” he noted. “This report is run every week automatically. We’re then able to pass this report on to providers, showing their patients’ recent fractures, and their exact deadlines for closing those gaps.”

Beginning in March 2019, the health plan has sent this actionable OMW list to providers on a weekly basis. Since then, it has seen a sustained increase in the number of gap closures for this measure, and internally projects that its OMW Star Rating will increase as a result.

In addition, the payer recently deployed an “eBrief” education campaign beginning in June 2019 to address NCQA’s exclusionary criteria for members with advanced illness and frailty, included in the HEDIS 2019 specifications. Provider feedback has been positive. “This campaign has led to more discussions with providers about these criteria,” explained the plan’s manager of healthcare data operations. “Providers have also expressed relief and excitement, because they can direct focus to other issues due to these exclusions.”

Be sure, however, to coordinate with your provider relations department to consolidate provider contact points and minimize abrasion. Overcommunication with providers can stifle collaboration.

      4. Improve your data exchange with providers.

Just last month, NCQA announced that Prenatal Immunization Status (PRS) will be the first Electronic Clinical Data System (ECDS) measure to be publicly reported; health plans will use the measure for the 2020 measurement year and report results in June 2021. As NCQA noted, “the ECDS architecture was designed to help HEDIS implementers understand how health IT can increase the efficiency of quality reporting, while also providing an incentive to connect to data in these other sources.”

Now is the time to work with your providers to improve access to electronic health record system (EHR) data, which will not only help you comply with these pending HEDIS requirements but improve your health plan ratings across other programs. Bringing the right stakeholders together to build a structured program to accept EHR data from providers is a necessity.

Laying the groundwork for success 

Conducting monthly proactive runs is not only a vital tool for improving your quality reporting outcomes, but an increasingly important way to keep both members and providers engaged in your efforts. Be very targeted in your approach—your resources are limited, so don’t dilute your efforts by trying to improve too many measures at once. By focusing your efforts on where you are most likely to gain the greatest return on investment, periodically adjusting and revising your approach, you will be able to slowly but steadily see continued improvement across all your programs from year to year.  

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). 


Branka Sustic currently serves as Vice President, Quality for Cotiviti. She has over 18 years of industry experience working with health plans/insurance companies, third party administrators, self-funded employers, reinsurance companies, and brokers. Throughout her time with Cotiviti, she has worked in several roles within the company’s Quality and Performance solution suite, leading the data operations team for Cotiviti’s Quality Intelligence client base since 2016. Sustic holds an undergraduate degree in Information Management and Technology from Syracuse University and a master’s degree in Health Informatics from Northeastern University.

This article is sponsored by:  cotiviti

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