Improving Your Health Plan’s HEDIS Performance

Our consultants have worked in a variety of management positions within commercial and government payer organizations, and average more than 15 years of experience. We understand your challenges firsthand, including competitive pressures, organizational obstacles, and limited resources.

Case Overview:

A Medicaid plan located in the northeast asked Change Healthcare Consulting to manage their HEDIS program and to help in-source their quality department operations. The customer was very concerned about its HEDIS program, as poor performance can result in regulatory non-compliance, significant financial penalties, risk of losing NCQA accreditation, and risk of losing a Medicaid contract.


The customer had an operations partner that had been responsible for all HEDIS technical and chart-chase operations, but the customer was concerned about the partner’s performance. Unfortunately, it was the operations partner that maintained the contract with the HEDIS vendor, making the situation even more complex. In addition, the consulting team had not been contacted until late fall, which meant they would need to develop and execute a new HEDIS program within weeks to be successful. In the midst of the assignment, this came to include developing new chart-chase capabilities due to the pandemic.


Change Healthcare deployed consultants to serve as interim HEDIS manager and HEDIS technical lead.

The consulting team first assessed and outlined the options for putting the new program in place. Based upon that analysis, the plan executed a new contract with the existing HEDIS vendor, as well as a contract with the former operational partner for short-term technical and advisory services. Once those key components were in place, the team was able to quickly develop the new program and move to execution within a few weeks.

The team analyzed all data inputs into the existing program and quickly identified and corrected some significant data deficiencies. These remediations included: increasing the plan’s service history by two additional years; significant improvements in the plan’s provider data extract to better support chart-chase activities; correction of diagnosis coding on 18% of the extracted claims; and the addition of claims data from other lines of business.

With the onset of the pandemic, the team quickly mobilized the plan’s internal resources to focus on chart-chase operations--specifically, extending existing remote EHR chart retrieval and adding new remote sites. The team also developed and mobilized a multi-phased escalation process to ensure that medical charts were obtained from all critical chart-chase locations.


In spite of numerous challenges, Change Healthcare Consulting succeeded in helping the customer build a new HEDIS program, greatly improving upon the previous year’s results. Even with the challenges brought by the pandemic, the plan increased its chart collection rate by 29%. That increase, combined with extensive data-remediation activities, allowed the plan to increase its rates across all state designated core measures, and across all but a few HEDIS measures. The consulting team also documented “lessons learned” and HEDIS best practices, and recommended the addition of new HEDIS data sources to position the customer for year-over-year improvement. Based on the success of this engagement, the health plan’s clinical leaders recommended Change Healthcare Consulting for additional work within the organization.

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