Three major types of payer record reviews are conducted every year: The Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Risk Adjustment, and Commercial Risk Adjustment. As the volume of payer and health plan reviews continues to climb, millions of patient records are requested. Hospitals, health systems, physician practices, and even ancillary care providers may be required to submit patient information to the payer or health plan, resulting in additional staff burdens and operational costs.
In fact, MRO in Norristown, Pennsylvania, a release of information (ROI) and HIM service, projects a 14% increase in review requests for 2017, especially as payers improve efforts to implement best practices and processes for quality reporting. Even HEDIS, the smallest of the three major payer review types, increased from 2% to 3% of the total medical record requests processed by MRO nationally from 2016 to 2017. HEDIS reviews are performed by payers and health plans to measure the quality and effectiveness of care delivered to their covered patient populations. For example, the STAR ratings reported by the National Committee for Quality Assurance (NCQA) are derived from these reviews.
In working with HEDIS and risk-adjustment reviews, several practical strategies have emerged to minimize payer-provider abrasion and reduce operational costs. This article explores a proactive approach to managing payer requests for records with emphasis on the industry’s next payer surge: HEDIS.