The final HEDIS® 2019 submission deadline is just over a month away—are you on track? In the latest edition of our blog series, “from the HEDIS® 2019 trenches,” Jenna Fitcher discusses what Cotiviti did this year to ensure medical record review validation (MRRV) success for our clients, and offers tips for health plans performing their own abstraction and over-read.
Where are health plans in the HEDIS process now that we’re nearing the end of the season?
We just hit the deadline for final numerator compliant counts on May 9, and health plans were informed by their auditors which 16 records from each group were selected for validation by May 13. Organizations are now sending selected records and all documentation to their auditor. This step is one of the most challenging of the season, because the auditor no longer tells the plan which numerators will be reviewed in advance. Instead, selection is based on new or revised measures, complex measures, or measures that the plan struggled with in previous years. Now begins the waiting game—did you have all steps in order this season to ensure MRRV success?
What should health plans with MRRV issues this year do to pass with flying colors next year?
Focus your over-read efforts on measures you think are most likely to be selected. In an ideal world, you could perform 100 percent over-read on all numerators throughout the entire season, but most health plans don’t have the resources it would take to do this.
We recommend the following strategies:
Start over-reading early
By starting over-reads early in the season, you can catch trends in errors as well as decrease the burden in the final two weeks of the season. This season, Cotiviti’s abstraction team began increasing over-read rates in early March to meet our clients’ MRRV goals.
Make a plan
Having a plan of attack for MRRV early in the season allows you to staff appropriately for over-reads later in the season. It also allows you to evaluate prior-year MRRV selections, new measures that have been added to the plan, and trouble spots from previous years, and it enables you to work closely with your auditor. Throughout the season, your plan may change, but it’s important to have a starting point, clear goals, and a thoughtful timeline. We usually see clients choose one of three strategies for MRRV:
- Focus on just one numerator within each measure group. Health plans that report hybrid data for only a limited number of measures often use this approach, as do plans with new product lines. The major advantages are you’ll have confidence in one numerator and will be able to pull fewer staff from abstracting to conduct over-reads. The biggest risk is that you’ve put all your eggs in one basket. If your auditor doesn’t select that measure for MRRV, you’re at risk of failing the selected measure.
- Focus on multiple numerators within each group. This tactic, which larger health plans often use, requires you to pull more abstractors for over-reads but covers a larger breadth of measures, giving you more security when your auditor selects measures for MRRV. This strategy allows you to spread over-reading more widely among your staff to leverage your resident experts on each measure. The breadth and depth can be any combination that works well for you. For example, we have worked with plans that successfully pass MRRV by over-reading 35 percent of all numerators, as well as plans that over-read 50 percent of two numerators. The strategy should fit your specific situation.
- Focus on specific measures regardless of how they’re grouped. You know your auditor will select a measure from each of the six groups, but sometimes it still makes sense to focus on multiple measures within one group, particularly when you’ve added NCQA measures to your products or when significant changes to numerator specifications have occurred. The downside of this approach, however, is you can put entire measure groups at risk of failing MRRV if you didn’t target them for over-read.
Watch seasonal trends
Finally, keep an eye on the quality of abstraction throughout the season so you can retrain or remove abstractors who are not meeting your quality goals. You also need to watch for trends in errors and address the underlying causes. Listen closely to your auditors’ feedback regarding medical record review. If they have concerns in certain areas, you may need to re-evaluate your plan.
What are some best practices for working with your abstraction vendor during MRRV?
Communicate with your vendor as early as possible about prior-year selections, new measures, measures you have historically struggled with, and your convenience sample. Work with your vendor to choose which over-read strategy makes the most sense for you. Once you choose, make sure you re-evaluate frequently based on quality scores, pain points, and auditor feedback. Don’t get so attached to your plan that you’re missing red flags during the season.
Stay tuned in June for our final report “from the trenches” for the HEDIS 2019 season.
Cotiviti Medical Record Abstraction services deliver rapid, accurate abstraction of clinical data components that document the provision of compliant care. Our goal is to achieve the highest number of compliant components possible within any reporting time frame, optimizing health plan quality scores and revenue while helping to close care gaps. Learn more from our fact sheet.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).