2 Main Ways Health Plans Can Eliminate the Fear of HEDIS Season

February 16, 2017

The fear of HEDIS® season is sometimes the motivational factor it takes, for health plans to seek outside assistance. HEDIS® is the primary measurement tool NCQA uses to assess their annual Final Health Plan Ranking; the industry standard for quality improvement. What health plans really need are more effective ways they to minimize the challenges of HEDIS® season.

Understanding the Challenge

There are some great insights contained in a white paper document by John Hopkins Medicine and created by Kohler Healthcare Consulting, Inc.  called: “HEDIS® Documenting and Reporting.”

The paper contains both comprehensive information, such as:

“National Committee of Quality Assurance (23 years) defines HEDIS as 'a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health care plans.'”

And, how about more detailed information like:

“HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.”

“HEDIS consists of 80 measures across 5 domains of care that address important health issues in 2014 and beyond.”

The Five Domains of Care:

  1. Effectiveness of Care
  2. Access/Availability of Care
  3. Experience of Care (Patient Satisfaction)
  4. Utilization and Relative Resource Use
  5. Health Plan Description Information

The document goes on to examine the 80 measures, breaking them up into three data collection methods:

  1. Administrative
  2. Hybrid
  3. Survey

Health plans benefit from understanding which areas in their services need to be improved, in order to receive a 5 star Final Health Plan Ranking each year from the NCQA. The main point is to be proactive in understanding the specific areas HEDIS® focuses on, which will lead to finding specific solutions for problems – without disturbing what works.

Pain Points & HEDIS Obstacles

  • The member is not continuously enrolled
  • The services are not documented properly in the member's medical record
  • Certain measures did not meet date parameters...
  • Appointment availability to members and provider's open hours
  • Members are assigned to the wrong PCP provider or information is not properly transferred to new PCP
  • Claims are submitted without the proper ICD-9 or CPT codes that count toward the measure

The reasons for these obstacles, or problem points, in a health care plans service are due, mostly, to their lack of membership engagement. When members are engaged, through methods such as in-home visits, close-by retail locations, through the mail, by phone, or online through their customer portal – useful data is compiled (health risk assessment, dates, times, screenings, etc.) and membership engagement is achieved.


The solution? Implement methods and tools to enhance membership engagement. Much of the inner workings of this solution are organizational and managerial methods to help engage members; the goal is for members to complete any: screenings, assessments, check-ups, lab and ancillary work, and any other health plan services needing to be completed for compliance and care objectives.

Here are some solution specifics:

  • Initial and annual wellness visits
  • Cloud-based technology to track patient release dates
  • Multi-media membership outreach strategy
  • Experienced physicians, nurses, and practitioners bringing care to the patient
  • Helpful online resources and call center reps
  • Large nationwide network
  • Innovative technology
  • In-home or close-by retail clinic visits
  • Membership access to HRAs through online portal


The main 2 ways health plans can eliminate the fear of HEDIS season are: understanding the challenge and implementing membership engagement solutions. Most of the commonly found “HEDIS® Obstacles” are, essentially, caused by a lack of membership engagement – likely caused by organizational, technological, and managerial issues.

The good news is MedXM specializes in helping health plans improve their membership engagement, through online technology, HRAs, a nationwide network of health care professionals and locations, and proven methods that have historically worked.

We're here to help health plans improve their quality star ratings and provide better service to their members – eliminating the fear of HEDIS® season is just an intrinsic bonus. Please contact us today to learn more.

Previous Article
6 Ways Millennials are Disrupting the Sale and Delivery of Healthcare
6 Ways Millennials are Disrupting the Sale and Delivery of Healthcare

6 Ways Millennials are Disrupting the Sale and Delivery of Healthcare

Next Article
5 Quality Improvement Tools You Should Be Using
5 Quality Improvement Tools You Should Be Using

5 Quality Improvement Tools You Should Be Using


Request More Information

First Name
Last Name
Thank you!
Error - something went wrong!