Blog | Healthcare Legal

Successfully Navigating the Surge in HEDIS Reviews

Blog | Healthcare Legal

Successfully Navigating the Surge in HEDIS Reviews

Greg Ford outlines three best practices insurance companies can follow as they prepare for HEDIS reviews.

Health plans and government payers conduct Healthcare Effectiveness Data and Information Set (HEDIS) reviews annually from January to mid-May, and the process typically is in full swing by March. More than 90 percent of all insurance companies participate in HEDIS to improve their Star ratings (as set forth for the Centers for Medicare & Medicaid Services) and quality scores. In fact, our experience in filling medical record requests for HEDIS and other payer reviews in 2017 demonstrates a significant increase in review volumes, especially as payers improve efforts to implement the HEDIS process.

As the volume of reviews climbs, providers incur additional staff burdens and increased operational costs. However, HEDIS also benefits providers. Providers gain the ability to view the effectiveness and quality of each health plan, which increases provider leverage during contract negotiations. Plans that perform well can command higher rates.

Preparing for HEDIS Season

Organizations preparing for HEDIS reviews in 2018 can follow these three best practices to reduce operational costs, ensure providers derive value, and ease provider-insurer friction.

Check in and reach out. Providers should find out which quality measures will be targeted for review in the year ahead. The 2018 National Committee for Quality Assurance’s quality measures for HEDIS are already published, so providers should reach out to their contracted government payers and commercial health plans now to discuss expected volumes and payment for providers’ efforts.

Anticipate request volume. Providers should immediately determine the number of record requests that will be received as part of the HEDIS review program, rather than wait until requests are received, to plan for the increased staff workload and operational costs required to produce the necessary medical record documentation.

Request compensation. Providers should ask government payers and commercial health plans to compensate for costs incurred during HEDIS reviews. Providers—or their designated release of information service vendors, now used by approximately half of all hospitals—are encouraged to invoice government payers and commercial health plans for time involved. Payment for HEDIS efforts ranges anywhere from $25 to $50 per patient record reviewed.

A Lesson in Efficiency

Several national health plans took a proactive approach to HEDIS communication in 2017. To coordinate their ROI efforts during the HEDIS review season, the plans opted not to engage a third-party vendor but, instead, to communicate directly with an industry-leading company that specializes in managing the compliant exchange of patients’ protected health information to establish a means for providers to communicate patient information and data with the health plan. The effort has improved the plans’ working relationships with providers while reducing operational costs, easing compliance with HEDIS timelines, and expediting the HEDIS process. 


Greg Ford is the director of requester relations and receivables administration, MRO, Norristown, Pa.

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