Healthcare Effectiveness Data and Information Set (HEDIS) is a performance measurement tool developed and administered by the National Committee for Quality Assurance (NCQA). Health plans across the United States utilize HEDIS to measure the effectiveness, availability and experience of care observed within a health care system.
The California Department of Health Care Services (DHCS) requires that the Alliance perform an annual compliance audit that conforms with a subset of HEDIS measures, referred to as the Managed Care Accountability Sets (MCAS). In addition, the MCAS includes performance measures developed by the Centers for Medicare & Medicaid Services.
Audit Purpose and Timeline
DHCS HEDIS audits assess how well the Alliance network of providers is delivering services to its patients. In addition, the audit subjects specific health care data elements to integrity checks, tests of completeness, transparency of reporting, compliance checks, and verification of services.
Audit periods runs from January through June and measure care that was delivered in the prior calendar year. The audit uses the term Measurement Year (MY) in reference to the year in which services have been delivered. For example, DHCS’ 2022 audit will assess compliance results from the 2021 service year.
HEDIS has two forms of data collection, Administrative and Hybrid. Administrative data collection is an automated, behind the scenes process of aggregating all electronic forms of data captured by the Alliance from multiple data sources. In instances where administrative data is not available, hybrid collection methods are used which captures compliance from medical records that are requested from providers.
During the scope of audit, providers are required to participate in the submission of medical records to support hybrid collection when requested by the Alliance and its partnered retrieval vendor. Providers should submit requested documentation within five days of any requests that are made.
Protected Health Information
Under the Health Insurance Portability and Accountability Act, data collection for HEDIS is permitted and health plan requests for medical records do not require additional patient consent or authorization. Alliance members’ PHI is maintained in accordance with all state and federal laws. Data is reported at an aggregate level without individual identifiers.
DHCS audit results are available every fall of the reporting year. The Alliance also reviews annual provider-level outcomes to assess areas where possible improvements can be made across its service network. From this assessment, Alliance Provider HEDIS awards are determined annually.