NCQA Releases HEDIS Compliance Audit Standards

The National Committee for Quality Assurance (NCQA) released its new NCQA HEDIS Compliance Audit Standards on April 8. These standards will verify health plans’ strict compliance with the Health Plan Employer Data and Information Set (HEDIS 3.0), a nationally recognized set of standardized performance measures.       

Since the July 1996 release of the HEDIS 3.0 draft (see Compensation &Benefits Advisor Update, 7/31/96), the nation’s largest private and public purchasers of health care have endorsed HEDIS 3.0.    

Every year, a growing number of health plans (more than 100 in 1996)submit to same form of “HEDIS Audit,” typically in response to re-quests from a large employer, public purchasers or business coalition. In addition, HCFA is requiring Medicare managed care plans to report selected HEDIS 3.0 data in 1997. Variability in the way health plans collect and calculate HEDIS data, and in auditors’ methods of verifying the data, how-ever, has raised issues related to the comparability of HEDIS results.

 “Employers and consumers need to have confidence that health plan quality information is accurate and comparable,” said NCQA President Margaret F. O’Kane.  “NCQA’s HEDIS Compliance Audit Program will ensure that it is, thus encouraging even broader use of HEDIS data in health care purchasing decisions.”     

 NCQA’s effort to standardize HEDIS auditing procedures has won broad support from the nation’s business coalitions and public purchasers including the Health Care Financing Administration (HCFA), the Pacific Business Group on Health, the New England HEDIS coalition, and the Gateway Purchasing Coalition. Employers, policy makers, consultants, and health plans have also expressed support for the work of NCQA’s broad-based Audit Committee, the group that developed the standards.         

NCQA’s HEDIS Audit Standards call for a two-part review of a health plan’s HEDIS collecting and reporting processes, including an overall in-formation systems capabilities assessment and an evaluation of the health plan’s compliance with HEDIS specifications. NCQA MEDIS Compliance Audits will focus on health plans’ data management processes and the mechanisms used to translate captured data into HEDIS statistics. Specifically, audits will examine the following:

• information practices and control procedures,
• sampling methods and procedures,
• data integrity,
• compliance with HEDlS specifications,
• analytic file production, and     
• reporting and documentation.        

NCQA HEDlS Compliance Audits will result in a “Report” or “Not Report” designation for each HEDIS measure audited. NCQA’s HEDIS Compliance Audit Advertising and Marketing Guidelines bar health plans from using measures receiving a “Not Report” designation in their advertising and marketing materials. In addition, all plans undergoing an audit will receive important feedback from their NCQA-certified auditors regarding the design of effective information control practices, methods to better comply with HEDIS specifications, and advice on streamlining data efforts. Health plans will learn the result of their audit approximately 4-6 weeks after the visit.            

“With the implementation of for-mal, standardized audit procedures the purchaser community can move beyond worrying about issues surrounding self-reported data from health plans,” said Fran Bastien, U.S. Health & Welfare Benefit Manager, Digital Equipment Corporation, and a member of the New England HEDIS Coalition. "This program will allow us to make progress on performance measurement and accountability with a higher degree of confidence in the information.”

 The NCQA HEDIS Compliance Audit Standards are available for purchase from NCQA’s Publications Center at 1-800-839-6487.

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