Phase 3: Post Onsite Activities

Our audit team will work closely with plan representatives following the onsite visit and will clearly communicate unresolved issues, deficiencies, and the potential effects on HEDIS data collection and reporting. Corrective and follow-up action and reporting will be coordinated and documented according to the HEDIS Compliance Audit methodology and may include additional questions about plan software, programming, manual processing, data input and output, and the effect of significant events, such as system conversion.

Within two weeks of the onsite visit, our audit team will prepare an initial report that:

• details any outstanding issues;
• lists any materials/documentation not yet received;
• assesses whether specific data requirements are met for each measure tested;
• lists all problem areas that require follow-up action before the final audit report is issued;
• identifies potential problems with measure rate integrity; and
• notes any measures which, based on current findings to that point, would not be reportable should no further action be taken to correct identified deficiencies.

Following the initial audit report, the organization will have an opportunity to correct any noted deficiencies or provide any additional documentation. The amount of time to accomplish these tasks will depend on the date of the onsite visit and the organization's reporting deadline.

An additional component of the audit is the validation of medical records that were counted as numerator positives. This medical record review (MRR) validation is performed if the hybrid methodology is used for any of the applicable HEDIS measures. The auditor reviews completed charts in which a numerator positive event was found in order to verify the accuracy of the health plan's findings. Depending on the plan's scheduling of medical record review, re-review for some plans may begin during the onsite visit.

Organizations will record HEDIS measure performance scores and rates using the NCQA Interactive Data Submission System (IDSS). This web-based tool is used to submit HEDIS results to NCQA and possibly to government agencies. The organization's auditor will review, benchmark, and validate all results. After approval, the auditor will then lock the submission tool and notify the organization of this approval. The organization will then submit the results to NCQA and other federal/state agencies, as required. Where applicable, the auditor will also review any local collection tools used by state agencies to record HEDIS and state-specific measures.

The audit team will then prepare a final audit report for each line of business audited. In addition to a summary of all findings and issues, the final report is comprised of three main parts. The first is the process review that will focus on how the organization collects, stores, analyzes and reports health information. Next, a measure-specific review will address compliance with conventional reporting practices and the HEDIS specifications. Lastly, the reporting rate and designations for every audited measure will be detailed.