It’s no secret… it’s the time of year for HEDIS reviews. While they’re about as fun as a root canal, they’re also just as vital as good dental care. Here’s some helpful information on HEDIS and the importance of these audits on compliance and reimbursement.  And… a little bit about how you can remove this burden if you’re ready to scratch it off your list!

What is HEDIS?

HEDIS is the Healthcare Effectiveness Data and Information Set. HEDIS is one of the most widely used sets of healthcare performance measure in the United States. This includes measures for physicians, PPOs and other organizations. [1] These are private payers looking at quality measures and metrics of data for specific clients.

Where do HEDIS Audits Come From?

HEDIS Audits come from the NCQA (National Committee of Quality Assurance) whose role as a non-profit committee is to make sure there is a measurement for patients’ quality of care. They are predominately in the private payer sector to gather data and information on different conditions and quality of care to determine how providers are paid in the future.

What are payers looking for?

Simply put, HEDIS is looking for quality data. The data that demonstrates the quality of care being provided to the patients by clinics and providers. In a nutshell, it’s a provider’s report card and financial reward for all the hard work within the practice.

Why are HEDIS reviews important?

Ultimately it impacts a provider’s contract negotiations with payers. The way healthcare organizations are reimbursed by commercial insurance is somewhat based on what the payers find in these audits. Accuracy = Money.

While HEDIS has a direct financial impact on a practice, that’s not all.  HEDIS season can pose a variety of challenges on healthcare organizations including…

  • Short straw: If you’re using members of your own staff to complete HEDIS, you may have had to promise the moon to the people who drew the short straw. These reviews are widely lamented by staff and often require some arm twisting and/or groveling, depending on your style. In addition to the wear and tear on the staff, it can also be costly because it often requires overtime hours to get the work done outside of the normal duties.
  • Seasonal staffing strife: Trying to find reliable, short-term staffing for HEDIS reviews can be both expensive and time consuming. Instead of taking a current member of your staff away from their current patient care, some resort to getting temporary or seasonal employees, which means training and managing someone who is only there for a short time. This approach often results in a time sink and always come with a compliance risk.
  • Outside in: Whether it’s a HEDIS auditor or a temp employee, having someone come in your office and work in your systems is intrusive. Navigating physical work spaces along with allowing someone you don’t know access to your EHR is a hassle for practice administrators. You not only have to make sure the auditors only have access to the information they need and restrict the rest of the PHI, you also have to continually monitor them while in the office.
  • Money pit: Whether HEDIS reviews are in your contract for no payment or negotiable, there’s a strain on you and your staff. Processing the audits and sorting out the financial and contractual obligations takes extra time and know-how.

Are there any charges if DataFile does reviews for us?

You’ve got enough financial burden as a healthcare organization, so we try to work through the charges with the requestor first.  Many times, we are able to collect a flat fee from the payer for each patient chart we copy. In many cases, the payer is referencing an outdated contract based on paper records and will indeed pay and expect to pay for the records they request electronically.

If the review is mandatory and the requestor states their agreement with you indicates records be sent at no charge, we’ll check with you first.  You can pull and review your payer agreement to confirm payment details, especially understanding the “purpose of” the review at hand.  If the requestor will not pay, we’ll quote you a competitive rate and give you the choice as to whether you want DataFile to handle the multi-patient review for you or if you want to handle in-house.

Why DataFile for HEDIS and reviews?

Nearly 80% of the audits that DataFile handles are HEDIS related, but we’d always love to tackle more. As your partner in disclosure management, we can help you avoid the extra work and headaches associated with HEDIS reviews. By working with a business associate like DataFile, you can keep your on-site staff focused on patient care and minimize the impact of HEDIS reviews on your practice — all for less than doing it yourself.

One of the greatest benefits we can offer our release of information clients is relief from the many burdens of HEDIS reviews. In fact, DataFile can handle all of your audits and reviews – as well as the time-consuming requests like subpoenas, deceased patients and workers compensation.  Talk with us about how you can say goodbye to HEDIS headaches for good! Reach out to your Production Manager today or contact us to find out how DataFile covers HEDIS reviews so you don’t have to.

Curious about how DataFile provides value in HEDIS reviews? Watch this webinar to learn more!

[1] http://www.ncqa.org/hedis-quality-measurement/hedis-measures