Lessons learned from the 2023 Prospective HEDIS® Season

Your 2024 HEDIS is submitted, you and your team have had time for a quick break, and now Plan Preview 1 is on the horizon. Your prospective HEDIS MY2024 season is already bustling along. But before you get too deeply immersed in this year’s prospective season, take a moment to review some of Astrata’s lessons from the 2023 season.

Which of these do you already have a handle on? Where should you be investing more planning time this year so that you can deliver a more effective MY2025 season and even greater impact next year?

1. Boost your source vigor. As you start your prospective season, be sure you are using (1) the most up-to-date unstructured data files (2) the full lookback period for each measure (3) interval updates in sync with any measures containing a time constraint or follow up (4) a wide enough range of sources (from provider feeds to aggregators to health information exchanges (HIEs). We see plans increasingly focusing on diversifying their data portfolio so that they can maximize the opportunity to close gaps during the prospective season.
2. Go to the MAX with your chart data. One clear result we saw in 2023 is that the impact of prospective review on your rates will be directly proportional to the volume of charts/gaps you review. No matter how big your plan is, you can cut the human effort to about 1/8^th of what you’d pay otherwise by using an NLP platform, and then redirect those averted costs to increase the number of charts you bring in. That produces more impact at the same cost.
3. Crank up the HEDIS engine. Being able to generate gap lists during your prospective season is a must for prospective review. And you’ll need next year’s measure definitions, if at all possible. If your vendor isn’t able to support a more nimble update schedule, it may be time to rethink that contract. As we move towards a digital ecosystem, you should expect your HEDIS engine to keep up with your new prospective workflows by turning over and refreshing logic much earlier in the season.
4. Get on the map. Keeping your review contemporaneous with your data and driving closures earlier in the year reduces unnecessary outreach and gives your QI team the maximum time to intervene. Mapping this year’s HEDIS codes and value-sets as early as possible helps ensure that you can start closing gaps as soon as your HEDIS engine turns over.
5. Stay strategic with your effort. Can your NLP platform provide strategic input to your prospective year by showing you where to concentrate your efforts and when it’s time to pivot to another measure? (hint – that’s a major feature of Chart Review 2.0). Ensure your managers and directors use team time to maximum benefit is table-stakes functionality for NLP systems these days.
6. Stay strategic with your data. With so much going on, it’s easy to lose track of the fact that this year is just one of many, and as HEDIS goes digital, clinical data becomes the lifeblood of quality. Planning for the future of your data sources and exploring the full range of options is a process that requires sustained attention. You can get a look at how some of our most advanced customers are thinking about data strategy in our clinical data toolkit.
7. Use the entire prospective season. As the hybrid methodology is retired, measure by measure, you can expect the work of hybrid season to gradually decline. You’ll be spending more and more time on prospective review in order to measure full compliance. Now is the time to expand your prospective season to the full-time period you have available, preparing for the new timeline ahead.
8. Stay up to date. You can rely on Astrata to provide the products and insights to help you make this transition. Be sure to follow us on LinkedIn!