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HEDIS Compliance: Are You in Control?

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The emphasis on quality within health plans is requiring flexibility as regulatory programs such as HEDIS, Star and HCC as well as provider contracts, incentives and internal operations require similar oversight, outreach and engagement. A few examples of flexibility that are needed are:

  1. Customize and implement HEDIS-like measures as proxy measures for monitoring STARs
  2. Executing multiple runs during a week for specific populations (e.g. MA population)
  3. Calendar year vs. rolling period runs

Given such varying scale of requirements, more and more health plans are looking to identify a solution that offers much more control and flexibility to meet current and long term strategic quality goals.

Historically, HEDIS Measures and supporting workflows have been treated as an operational initiative where most health plans have preferred using a cloud vendor to calculate and submit overall compliance to NCQA. These implementations, while meeting the basic needs, offer minimal room for innovation/ enhancements to the health plans. As more and more health plans are moving towards value based contracting with their provider partners and as the government requires scores for marketing and reimbursement, the industry is looking towards bringing the HEDIS solutions under their control to drive not just HEDIS reporting, but also additional use cases such as care management, gaps-in-care, provider reimbursements, others to take them through the next few years of healthcare industry evolution!

 

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