medicare advantage

HEDIS Supplemental Data

Health plans rely on accurate and complete data for HEDIS metrics across a broad spectrum of initiatives including NCQA Health Plan Ratings and programs like the Medicare Advantage Star Ratings and state Medicaid Pay for Performance (P4P) quality initiatives. Plans are forced to depend on the completeness of the data coming from their claims processing systems.

The reality is that claims data can create false positives (you report a gap in care where none exists). First, a plan's claims may not reflect a member's full history. There may be prior procedures or conditions that are not reflected in the claims data. Second, providers do not always code an encounter to allow you to get credit. This is especially true of measures that might not change reimbursement such as Adult BMI. Finally, gaps may be due to coding errors, a problem that will get worse with the transition to ICD-10. Avior's analysis of one plan's HEDIS data indicates that at least 7% of HEDIS tasks could not be counted because of coding issues.

Gathering Supplemental Data

NCQA allows plans to gather supplemental data for HEDIS reporting. Requirements for supplemental data are summarized in General Guideline 39 from NCQA. Plans use methods like site visits and medical records retrieval services to gather supplemental data. However, these are expensive and time consuming processes. Avior BenchMark automates the complex interactions between plans and their providers which dramatically reduces cost. We call the workflow to gather supplemental HEDIS data the Virtual Chart Review. Like traditional methods, the Virtual Chart Review gathers supplemental data in accordance with NCQA and CMS requirements. Since every task is tracked at every step in the process, audit capabilities are built in to the system.

Task Management for Gaps in Care

The Virtual Chart Review workflow is part of our Supplemental Data Module that uses Avior BenchMark , our Software-as-a-Service (SaaS) platform. This allows you to quickly and efficiently manage the interaction with your providers on their HEDIS metrics for your plan. We import HEDIS metrics by provider and member from your existing reporting system then our platform identifies the gaps in care for each provider, giving them easy-to-view reports and tools by member. Rather than relying on complex reports to communicate with providers, the system makes each open care metric into a task. This allows busy offices to get you the information you need without the overhead of pulling a full medical record. It is important that the task be granular. In our process, each task addresses a provider about a specific patient and procedure.

Get Your Providers to Take Action

Tasks must also be actionable. Providers give on-line feedback on each task in a closed loop process that optimizes results. They can securely submit the necessary documentation to close the task. This continuous improvement process helps improve and protect your rating by addressing all gaps in care. Our system ensures that this new data flows through to your HEDIS reporting system.
It is critical that you give your providers actionable information on their activities that drive your HEDIS metrics and give them a means to securely communicate back to you. For example, MA compensation depends on what your providers do since HEDIS metrics in domains 1 and 2 account for more than half of your part C rating. However, those are the components that are least in your control since most HEDIS metrics reflect provider behavior. Too often, health plans focus on informing the member rather than engaging and influencing the providers.

Proven Platform for Provider Engagement

Avior's BenchMark platform is designed to manage large scale programs in dealing with risk and compliance issues for large groups of third parties, like provider networks. Automating routine tasks allows you to focus resources on finding and fixing problems. We have proven this approach with our ICD-10 Provider Readiness Solution Pack in the largest payer environments. Our secure on-line approach gives the provider all of the information they need to be successful. Most importantly, the platform allows for feedback from the provider so you can monitor your progress toward a higher rating. This module can be expanded into a full Star Rating or P4P program management platform.

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The Virtual Chart Review

What is a virtual chart review?  It's better way to get supplemental data from your providers and cut costs.  Click on the video to see our 2 and 1/2 minutes explation:

video playback


Watch the Webinar

5 Lessons from the Latest CMS Star Rating Data

In October, CMS released the Star Ratings which includes an enormous amount of data about the performance of all MA contracts. Avior has combined this data with enrollment data and done an extensive analysis. We want to share 5 critical lessons from this analysis:

  • Why one metric can tell you how well your providers can code
  • Which key metrics can be your canary in the coal mine
  • What enrollment trends tell us about how consumers view quality
  • How much of your rating is based on your location
  • How to compare your results to your competitors

These insights are important to anyone responsible for managing a plan's MA star rating. Join us for this 30 minute overview of our findings.


Did you miss our most recent webinars on Using Provider Engagement to Improve Your Star Rating? Watch the replay here.

Webinar Replay

Audit Ready Supplemental Data

Payers must engage their providers if they are to benefit from a sustained improvement in HEDIS metrics. This webinar will discuss the process of gathering supplemental data to bolster your HEDIS rating. Automating the process of working with providers to get the required data can have a significant ROI, but only if you meet CMS and NCQA standards.  Medicare Advantage plans need a robust and auditable process to correct problems in your data, focus on the real gaps in care and get the rating you deserve.

 Webinar Replay

Did you miss our most recent webinars on Using Provider Engagement to Improve Your Star Rating? Watch the replay here.

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