To build a successful quality improvement program, health plans not only must stay ahead of annual changes to HEDIS® reporting requirements, but also a continually expanding list of state and other custom measures to track as well. Amid all this change, Cotiviti’s Quality Intelligence solution recently earned full certification for its Quality Engine application from National Committee for Quality Assurance (NCQA) for all HEDIS Measurement Year (MY) 2020 measures—marking the 20th consecutive year that Cotiviti has earned this certification. The solution was also certified for 22 California AMP measures. To mark the occasion, we spoke with Cotiviti’s Branka Sustic, vice president of data operations program management, who reflected on the continuous evolution of Cotiviti’s quality measurement solutions as well as health plans’ changing needs and goals.
You’ve been with our organization yourself for 20 years. Tell us about your current role on Cotiviti’s quality team and what keeps you busy from day to day.
Ultimately I am responsible for the day-to-day operational delivery of our HEDIS solution as well as HEDIS retrieval and abstraction to our client base. This includes everything from supporting the implementation process all the way through HEDIS submission. My responsibilities also include ensuring that the data analysts are providing the necessary knowledge to our clients around the value of certain data elements that are necessary to feed our engine and being able to explain to our customers how we implemented HEDIS measure logic.
I'm also responsible for our program management support services for HEDIS retrieval and abstraction. My team serves as an intermediary between our retrieval and abstraction operations and our clients; they are the client-facing team updating the clients on the status of where they are in the season, how far along we are with the project, and when they expect the project to complete. Finally, I oversee our HEDIS program managers, those who are responsible to work with our clients and help guide them through the HEDIS season. So, it really spans a number of different responsibilities, but if you're thinking of the overall HEDIS project, my team is really the day-to-day support for our clients to help them be successful during the HEDIS season.
How has quality reporting gotten more difficult for health plans in the past several years, and what is Cotiviti doing to help them with those problems?
When I started working on HEDIS, we had very few clients who really performed HEDIS year-round, treating it as a regulatory task to perform once per year. It has gotten much more complex because a lot of plans are now using that HEDIS data throughout the entire year to feed different components of their programs, whether it's provider pay-for-performance, or submitting measure results to different states, or feeding different internal dashboards projects that the plans have.
We have seen a tremendous shift in that focus on just the HEDIS season to using HEDIS data around the clock to feed different health plan initiatives. We have continually supported our clients in these initiatives. So, instead of running the data once a year or four times a year, just for HEDIS purposes, we have seen a big uptick on helping our clients do year-round activities.
We have regular touchpoints with NCQA’s audit and measures teams to discuss trends in market and topics relevant to our client base. This is something we look forward to continuing and building upon in the future. One other major way we help our clients be successful is through our partnership with the auditor firms. In the HEDIS world, every plan has an auditor and goes through the audit process every year before submission. What we have done is hold two annual auditor open houses, where we have gotten great participation and feedback. It's an opportunity for us to share information about our products with the auditors so that they can have a better understanding of our tools—so that once the audit time comes, they can better service our joint clients.
Clients often request HEDIS data to use for downstream reporting in their own reporting environment. As a result, we have developed a standard extract offering that meets the needs of the majority of our clients. For clients who need more than the standard extract, we have developed a structured custom request intake process. Sometimes the custom work is a fairly quick task, other times it’s a longer-term initiative requiring custom development, but either way we work collaboratively with the client to get it done. We make sure we understand the underlying business need to help the client arrive at the most effective solution.
In 2020, we also formed a new partnership with Health Data Decisions (HDD) to help clients who could benefit from additional service, particularly when there is high turnover or limited resources within their quality department. Some examples include offering education about what HEDIS is and its importance to a health plan or looking at the client’s internal data warehouse(s) and making sure the client is mapping all of the fields that it should be mapping. HDD can help clients take full advantage of the data streams and elements that they have in their possession but might not be passing through to Cotiviti today. It could have an increase on your rates if you are passing more data, or better data. If plans are lacking IT knowledge or data knowledge, this is where the HDD team can step in and provide that assistance.
How have Cotiviti’s solutions evolved in the time that you've been with the quality team?
What stands out to me the most is how we have really adapted to the requirements of the quality improvement business and the regulatory requirements of NCQA. Some of the things that I have seen us enhance specifically have been state and custom measures, expanding our library and offering—that really is driven by our customers' needs to report for different Medicare or Medicaid requirements.
I have also seen us, as an organization, become much more effective with our processes and servicing our clients in a more efficient manner. We have continually improved our teams’ skills to be able to meet the demands of our customers and the market in order to serve our clients better. One of our most important core values is customer success and we are a strategic partner in helping clients have successful HEDIS seasons. Industry-wide, Cotiviti’s Quality Engine is used to process the most lives annually for HEDIS submission purposes. It's something we are proud of, and I strongly believe this is a result of hard work done by all our teams. We have the strongest development organization in the industry that consistently delivers a product with the lowest recertification rates and coupling that with our extraordinary service delivery teams creates a best-in-class HEDIS offering for our client base.
By listening to our customers, we have also made great strides in product development. One of the things that we are very proud of this past year, and are continuing to do in 2021, is upgrading our customers to our Quality Reporter Web solution. This will help our clients do a better job with their own abstraction activities, offering real-time reporting of their hybrid measures.
In developing Quality Reporter Web, we worked very closely with our product advisory board, which is really a quorum of select clients who provide feedback, offering us early insights into the development areas and serving as our testing ground for different types of ideas. We have gotten great feedback from clients who have already implemented this new solution. It’s really one of our flagship items that we are very proud of, and it has definitely contributed to the evolution of our product line.
Looking toward the future of quality improvement, what excites you the most?
Quality in and of itself is very regulatory in some ways—health plans have to do it. However, what I find exciting is that health plans are taking on new initiatives not because they have to, but because they want to better feed their other downstream processes.
NCQA is pushing a technology initiative for health plans and quality vendors. This includes the incorporation of FHIR and interoperability, which Cotiviti is excited to tackle. The ability to receive a standard format of measure code in the clinical quality language (CQL) from NCQA is another item that we are eager to implement.
About Branka Sustic
Branka Sustic has led the data operations team for Cotiviti’s Quality Intelligence client base since 2016. She has over 18 years of industry experience working with health plans, third-party administrators, self-funded employers, reinsurance companies, and brokers.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).