Health plans and government payers conduct Healthcare Effectiveness Data and Information Set (HEDIS) reviews annually from January to mid-May, and the process typically is in full swing by March. More than 90 percent of all insurance companies participate in HEDIS to improve their Star ratings (as set forth for the Centers for Medicare & Medicaid Services) and quality scores. In fact, our experience in filling medical record requests for HEDIS and other payer reviews in 2017 demonstrates a significant increase in review volumes, especially as payers improve efforts to implement the HEDIS process.
As the volume of reviews climbs, providers incur additional staff burdens and increased operational costs. However, HEDIS also benefits providers. Providers gain the ability to view the effectiveness and quality of each health plan, which increases provider leverage during contract negotiations. Plans that perform well can command higher rates.