HEDIS Audit – Appropriate Monitoring and Oversight of Vendors

1. HEDIS Audit – Appropriate Monitoring and Oversight of Vendors Presenter: Yolanda Strozier, MBAProject Manager, EQRO Services

2. HEDIS Compliance Audit Standards • Describe requirements for HEDIS® data collection and reporting processes. • Used to assess the organization’s ability to report HEDIS data accurately and reliably. • Identify what plans should strive towards in order to accurately report HEDIS measures. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

3. What is a Vendor in the Context of a HEDIS Audit? Vendors fall into two broad categories: • Vendors who process data • Vendors who collect and calculate performance measures

4. Vendor Oversight Vendors who process data: Any vendor which processes claims data and provides an encounter data file to the MCO {i.e. independent physician associations (IPAs), lab vendors, other health plans, management service organization (MSO)}.

5. MCO Responsibilities Regarding Vendors Who Process Data • Ensure that encounter level data from the vendors are accurate and complete. • Communicate and enforce data quality standards (typically these are addressed in the vendor contract).

6. MCO Responsibilities Regarding Vendors Who Process Data • Require data submission from vendors on a timeline consistent with HEDIS reporting time frames. • Periodically review and measure vendor performance against quality and timeliness standards.

7. Audit Standards and Examples of Appropriate Monitoring of Data Processing Vendors Medical Services Data – Sound Coding Methods and Data Capture, Transfer and Entry • Monitoring vendor data error reports and subsequent resolutions. • Review of policies and procedures on claims processing. • Annual site visits.

8. Audit Standards and Examples of Appropriate Monitoring of Data Processing Vendors Enrollment Data –Data Capture, Transfer and Entry • Review of policies and procedures on enrollment file processing. • Annual site visits. • Evidence of appropriate turn-around time for processing of eligibility/enrollment data.

9. Audit Standards and Examples of Appropriate Monitoring of Data Processing Vendors Practitioner Data – Data Capture, Transfer and Entry • Review of policies and procedures on provider data processing. • Annual site visits. • Certification reports for credentialing. • Review and validation of a sample of provider credentialing files.

10. Vendor Oversight Vendors who collect and calculate performance measures: Any vendor delegated to collect, calculate, and/or report HEDIS data must comply with all relevant standards.

11. Audit Standards and Examples of Appropriate Monitoring of Calculation Vendors MCOs must ensure that all vendor work products meet audit standards, including: • Vendor data collection tools and instructions • Vendor administrative databases, policies and procedures • Vendor HEDIS data submissions • Vendor error and deficiencies • Data flow among vendors

12. Audit Standards and Examples of Appropriate Monitoring Auditors will: • Confirm that the vendors follow HEDIS administrative data specifications. • Assess whether the vendors have accurate medical record data collection tools and a sample of completed data collection tools.

13. Audit Standards and Examples of Appropriate Monitoring of Calculation Vendors Vendor rules of thumb: • The MCO is ultimately responsible for all vendor activities. • Spell out expectations clearly in vendor contracts. • Formally document all oversight activities. • Validate a small sample of vendor data (medical record review, HEDIS numerators and denominators) • Always perform a reasonability check of final calculated rates.

14. Questions and Answers