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analysis: NCQA suspends PLD file requirements for HEDIS® 2018

December 07, 2017

Last week, the National Committee for Quality Assurance (NCQA) informed health plans, vendors, and auditors that it has decided to suspend the requirements for the Patient Level Detail (PLD) files for Medicaid, Marketplace, and commercial populations for HEDIS® 2018. The organization noted that the decision was a direct response to “comments about the number of measures and the burden of the work associated with collecting and reporting the data.” Here, Jamison Gillitzer, product manager for Verscend’s Quality and Performance solutions, breaks down the announcement. 

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Why was this requirement burdensome for health plans? 

It was primarily used as an audit tool but was labor intensive for plans, vendors, and auditors, and very time consuming to deliver. In the past, this file was required with each NCQA submission and included the raw data behind a health plan’s rates. Plans needed to create one of these files for each IDSS submission and validate each against their IDSS submission. If you had 10 IDSS submissions, you would need 10 PLDs.


On top of this, the member-level detail in the PLD had to perfectly “balance” with your rates for auditor approval and submission. If everything didn’t perfectly balance, you would need to correct, re-generate the PLD file, and go through the validation process again. The file itself is also large and can be complex to deal with, especially for plans not using a vendor and therefore having to carry that burden themselves.

How will health plans benefit from this decision during HEDIS® 2018? 

Since the medical record review validation (MRRV) submission deadline was moved up in the timeline to May 9, 2018, this decision frees up plans to focus on preparing records for this portion of their audit. They can perform additional over-reads and quality checks on their abstracted records. In general, this gives health plans a little more breathing room to button things up for the MRRV submission process. Plans will also no longer have to worry about these PLD requirements between MRRV completion and IDSS plan lock, making for a more streamlined submission.


What is your interpretation of the following NCQA statement?

As we continue to explore ways to improve quality measurement while reducing the burden of the HEDIS and audit processes, more efficient and robust methods for data reporting are a priority. As part of that effort, we are evaluating alternate ways of specifying, developing, collecting and reporting HEDIS measures. We anticipate that this new, future-state approach will reduce the complexity of measure specifications, allow for more granular comparisons of plans by geographic and patient characteristics, and allow auditors to follow one data stream from the start of the measure calculation to the final reporting.

I think this largely has to do with NCQA’s rollout of clinical data, or “eMeasures.” The organization is attempting to create more measures that come directly from electronic clinical data systems to reduce chart review burden. Up to this point, plans have had trouble accommodating these new measures, which remain in a “first year” status, meaning they don’t need to be reported. By removing PLD requirements, NCQA is freeing up capacity for plans to work through any difficulties they are having with this new measure type.

We’re less than three weeks away from the kickoff of HEDIS 2018. What should health plans ideally be doing in these final few weeks of 2017? 

Plans should be concluding their test runs and analyzing the results to ensure proper data formatting. They should also be testing chase logic and cleaning up any last-minute provider and location information. Finally, plans should begin training their abstraction staff, planning IRR testing, and customizing their vendor’s data collection templates if applicable.


Are you prepared for HEDIS 2018? Download our latest checklist for “lessons from the trenches” to help guide your HEDIS measurement and reporting efforts in the new year.

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Jamison Gillitzer is a product manager supporting Verscend’s Quality and Performance solution suites. His primary responsibilities are the successful delivery of our quality solutions to ensure they meet clients' needs in support of HEDIS, P4P, and other quality reporting initiatives. He also works to develop and enhance our capabilities to support evolving quality requirements. Jamison has a bachelor's degree in entrepreneurial management from the University of Minnesota and is PMC-III certified.

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