Risk Adjustment

New NCQA Changes For HEDIS Reporting Will Affect All Health Plans

Sujata Bajaj
Written By
Sujata Bajaj
Vice President of Product and Payor Solutions

New NCQA HEDIS Changes: What You Need To Know

NCQA issued important changes in order to increase the consistency and reliability of HEDIS data submissions. The new requirements will change HEDIS reporting for all health plans, but could be significantly more time consuming and costly for some.

Here’s what you need to know.

Health Plans Must Use a NCQA-Certified Vendor or Contract With NCQA

For dates of service no later than 2021, for reporting in 2022, all commercial, Marketplace, Medicaid and Medicare health plans must use an NCQA-certified HEDIS vendor or contract directly with NCQA to verify that their measures are correct and logical.

For health plans who opt to do it themselves—starting in 2019, for reporting in 2020—
they have to contract with NCQA using their test deck process known as Automated Source Code Review.

The fee will be $350 per measure and $1,000 per IDSS submission, per member, per year based on membership size. With 81 measures total and 51 for Medicare alone, this can get costly for health plans looking to do it on their own.

The timeline is brief—between October and February—but because it overlaps with HEDIS, the process can be challenging.

The NCQA test decks are written to test measures for Marketplace, Medicare and Medicaid that overlap so Medicare-only plans for example, will now need to show they can pass for all three lines of business. This will certainly be an arduous, time-consuming and costly process for an internal IT team to do on their own and keep up with the changes every year.

3 Things To Look For In A NCQA-Certified Vendor

Aside from the expertise only a NCQA-certified vendor can provide, you’ll also have the advantage of a community of health plans who are using the same tools and can offer tips and advice.

When evaluating potential vendors, look for those that fit the following criteria.

1. Experience
Choose a vendor who has a wealth of experience, expertise in all the quality areas and the know-how to identify your data anomalies.

2. Communication
It’s important to choose a vendor who offers comprehensive solutions that focus on account management and one who provides expert guidance about timelines and deadlines so you can stay on track with your HEDIS submissions.

3. Transparency
Gathering the data and calculating the measures isn’t enough. You need a vendor who can provide a 360-degree view of your data and help you understand how they calculated the denominator and numerator, which group is the numerator negative and why, for example.

To ensure you’re prepared for reporting in 2020, we recommend partnering with a NCQA-certified vendor by January 2019. To learn more about Episource’s comprehensive HEDIS analytics and reporting solution, contact us today.

Sujata Bajaj
Sujata Bajaj
Vice President of Product and Payor Solutions
Su has built extensive solutions for payors, including ACOs, Medicaid, MA, and the ACA exchange. She uses technology to integrate Revenue Programs with Quality and Care Management while maintaining a dedication to adding value to the beneficiary’s experience with the health plan through those solutions. Su has a Bachelors in Economics from Northeastern University in Boston, MA and is a Six Sigma Yellow Belt.

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