In my final blog in this HEDIS series, I want to touch on the many facets of collecting and using data. Data collection is one of the biggest challenges health plans face in preparation for HEDIS measures. Supplemental data sources present opportunities to improve performance rates, but the rules around the usage of supplemental data can be a bit of a challenge.
Let’s start with some basics. Supplemental data collected and reported in conformance with HEDIS requirements can improve rates when data capture from standard administrative claims information is generally low. Supplemental data can also be collected year-round, which could improve the efficiency of data collection and deliver visibility into performance rates on an ongoing basis.
But supplemental data does have some exclusions of use. The good news is it can be used for numerator events or services and for required and optional exclusions. NCQA has clarified that supplemental data may be used to determine members in hospice and members who have died. However, the list of exclusions is longer and includes denominator events, measures with no numerators, clinical conditions that change, and risk adjustment.
Why Supplemental Data Is Tricky
Supplemental data generally falls into two categories: standard and non-standard, with very specific uses for each type. It’s important to understand the different types of data and how they can be used.
Standard supplemental data refers to electronically generated files that come from providers who rendered a particular service. Auditors will review the policies and procedures related to the management of standard supplemental data ensuring stability year to year, but these files are not required to be accompanied by proof-of-service documents unless requested specifically by the auditor.
However, files must have standard file layouts, standard data fields and industry-standard codes, and must include all elements required by measure specifications, including payment status when applicable. In order to maximize use of standard supplemental data, provider type and location of care must be available.
As NCQA continues to align quality measurement programs for health plans and providers, the collection of data from certified eCQM vendors can be used as standard supplemental data when certain criteria are met. Health plans need to articulate a clear data flow process in the ROADMAP and the eCQM vendor’s certification report must be available by the certification deadline.
Non-standard supplemental data capture missing service data not received through structured electronic sources, such as claims, encounters or other transactions or standard supplemental sources. Data collected by a plan, a provider, or a contracted vendor might include sources that are not stable over time.
Organizations must have documented processes for the collection of non-standard supplemental data, including clear policies and procedures for collection and validation. In terms of audit requirements for non-standard supplemental data, a sample of records selected by the auditor must be substantiated by proof-of-service documentation, i.e., a copy of information from the member’s chart from the service provider or the PCP, from the legal health record. Proof-of-service documentation must identify that the service occurred within the timeframe required by the measure. Documentation that the service was ordered is inadequate for proof-of-service, and there are various types of documentation that are not allowed, including member surveys.
As with standard supplemental data, non-standard supplemental data files must have all data elements required to meet criteria as noted in the measure specifications, including payment status when applicable. Although supplemental data may be collected throughout the measurement year and standard supplemental data can be collected through the end of the first quarter, data collection for non-standard supplemental data must be completed by the deadline listed in the Audit Timeline, generally by the first of March.
Auditing Supplemental Data
In addition to the specific audits of standard and non-standard data, there are general guidelines for audits of all supplemental data, which include an annual review. At a minimum, the annual review must have these items for each supplemental data source:
- A completed Supplemental Data section of the HEDIS Roadmap, including all internal and external processes, validation and expected impacts of the data source
- Impact of the supplemental data source by measure
- Primary source verification where required or requested by the auditor
- A final certification report for supplemental data from a certified eMeasure vendor
Supplemental data that does not pass all audit validation steps by the deadline may not be used to calculate HEDIS rates. A best practice is to annually review all supplemental data sources to assess the value of the data source relative to the annual collection and validation effort.
How We Can Help
I hope our blog series discussing strategy for understanding an effective HEDIS program has been helpful. Now I’d like to take a moment to let you know how we can help. Identifying and resolving care gaps are essential to improving member health outcomes and performing well with HEDIS measures. Each year, you face the need to meet new data and performance measurement challenges. We offer health plans of all sizes and lines of business in an integrated, state-of-the-art solution for HEDIS. SS&C® CareAnalyzer features:
- NCQA certified measures
- Calculation of CAHPS survey samples
- Calculation of hybrid measure rates
- Manual entry of medical record data
- Support, training, and annual measure updates
Download our Checklist for Choosing a HEDIS Vendor to see if it might be time to make a switch.
Written by Amy Salls
Sr. Director, Revenue and Quality Analytics