Improve HEDIS Measures: What Health Plans Need to Know

Health plans invest millions in HEDIS improvement each year, yet many watch the same measures stall year after year. The problem usually isn't clinical—it's that documentation of completed care never reaches the plan.

This guide covers how HEDIS measures work, why scores plateau despite significant effort, and the communication infrastructure that drives sustainable improvement.

What HEDIS measures are and how they are scored

Improving HEDIS performance takes more than a year-end push. It requires shifting from retrospective chart-chasing to continuous, data-driven gap closure throughout the measurement year. HEDIS—the Healthcare Effectiveness Data and Information Set—is NCQA's standardized system for measuring health plan performance. Health plans report HEDIS data annually, and those scores directly influence Medicare Star Ratings, accreditation status, and how members choose their coverage.

NCQA organizes HEDIS into six domains:

• Effectiveness of Care: Tracks whether members receive evidence-based preventive and chronic care services

• Access/Availability of Care: Measures how easily members can obtain appointments and services

• Experience of Care: Captures member satisfaction through CAHPS surveys

• Utilization and Risk-Adjusted Utilization: Monitors appropriate use of services like imaging and hospitalizations

• Health Plan Descriptive Information: Provides context about plan enrollment and demographics

• Measures Reported Using Electronic Clinical Data Systems (ECDS): Captures quality data directly from certified EHR systems

Most HEDIS measures are calculated using administrative claims data. However, supplemental clinical data—records submitted outside the claims process—increasingly fills gaps where billing data falls short.

Why improving HEDIS measures matters for health plans

HEDIS scores carry real financial weight. CMS uses specific HEDIS measures to calculate Medicare Star Ratings, and plans with higher ratings receive quality bonus payments totaling $13.4 billion in 2026. Conversely, plans with consistently low scores face enrollment restrictions and reduced bonus eligibility.

Beyond reimbursement, HEDIS performance shapes how members and employers evaluate health plans. Published scores influence enrollment decisions, and NCQA Health Plan Accreditation depends heavily on demonstrated quality improvement.

Here's what often gets overlooked: HEDIS scores reflect a plan's ability to coordinate care across fragmented provider networks. When gaps remain open, it usually signals that clinical information isn't flowing between the plan and the providers responsible for member care. The care may have happened—but the documentation never arrived.

Common barriers to improving HEDIS scores

Most health plans invest heavily in quality improvement, yet many struggle to move key measures. The underlying challenge often isn't clinical intent. It's communication and data flow.

Incomplete and fragmented clinical data

Clinical encounters happen every day that never appear in claims data. A member completes a mammogram at an independent imaging center, but the plan never receives documentation. Supplemental data can fill gaps like this, though obtaining records from providers outside the plan's direct network remains difficult and time-consuming.

Inaccurate provider directory information

Outreach campaigns fail when provider contact information is outdated. Providers frequently change locations, affiliations, and communication preferences. Plans often don't learn about changes until a fax bounces or a letter returns undelivered. Every failed outreach attempt represents a missed opportunity to close a care gap before the measurement year ends.

Manual chart chase workflows

Chart chase refers to the labor-intensive process of requesting medical records to document completed care. Many plans still rely on fax-based requests, which delay data collection and burden staff with manual follow-up. Error rates climb when teams manage hundreds of outstanding requests through spreadsheets and email threads.

Delayed notifications on transitions of care

Hospital admissions, discharges, and transfers trigger HEDIS measures like Transitions of Care (TRC). TRC measures require medication reconciliation and follow-up within specific timeframes—often 30 days. When plans receive ADT notifications late, or not at all, timely outreach becomes impossible.

Member outreach disconnected from provider workflows

Health plans often run member-facing campaigns without informing the providers responsible for delivering care. A member receives a reminder to schedule a screening, but their primary care provider has no visibility into the open gap. Without that connection, the member becomes the messenger—and outreach rarely translates into completed care.

Strategies to improve HEDIS measures

Effective HEDIS improvement requires more than member engagement. It requires reliable communication infrastructure that connects plans to the right providers at the right time.

1. Prioritize high-impact measures tied to Star Ratings

Not all HEDIS measures carry equal weight in Star Ratings calculations. Focus resources on measures with the greatest Star Rating impact—like breast cancer screening, blood pressure control, and medication adherence—to deliver the highest return on quality improvement investment.

2. Expand supplemental data sources beyond claims

Clinical data from EHRs, health information exchanges, and provider-submitted documentation often captures care that claims miss entirely. ECDS measures specifically require electronic clinical data, not claims. NCQA's ECDS special report found that plans investing in supplemental data ingestion consistently outperform plans relying solely on administrative data.

3. Automate care gap notifications to the right providers

Closing gaps requires activating the provider responsible for the member's care—not just sending a generic notification. Automated, targeted notifications reduce manual outreach burden. However, success depends on identifying the correct provider, location, and communication channel. Accurate provider directory data and intelligent message routing make the difference between a notification that gets acted on and one that gets ignored.

4. Close transitions of care measures with real-time ADT

Real-time ADT event notifications enable timely post-discharge follow-up. TRC measures require medication reconciliation and provider follow-up within specific windows. Delays in receiving discharge information make compliance nearly impossible. Reliable communication with the receiving provider determines whether TRC measures close.

5. Reduce provider abrasion with workflow-friendly communication

Providers often ignore outreach that disrupts their workflow. Delivering gap notifications through channels providers already use—EHR inbox, Direct Secure Messaging, or fax—improves response rates. Reducing provider burden isn't just courteous. It's operationally essential for gap closure.

How provider communication drives HEDIS gap closure

Here's a perspective that often gets overlooked: HEDIS improvement is fundamentally a communication problem. Clinical care frequently happens, but the documentation doesn't reach the plan. The member completed their screening. The gap remains open because no one sent the results.

Closing gaps requires identifying, reaching, and activating the right care team.

Identifying the right care team for every open gap

Determining which provider to contact for a specific gap isn't straightforward. Members see multiple providers, and the physician who ordered a test may differ from the one who can close the gap. Provider relationships, locations, and specialties all affect routing decisions. A continuously maintained healthcare communication directory helps plans route notifications to the correct recipient rather than a generic office fax number.

Reaching providers through Direct Secure Messaging and intelligent eFax

Direct Secure Messaging is a secure, HIPAA-compliant electronic communication standard that enables clinical document exchange. However, relying on a single channel limits reach—not every provider has an active Direct address. Intelligent routing that selects the best available channel for each provider maximizes delivery success.

Platforms like careMESH CONNECT combine directory data with intelligent routing to address this challenge, helping plans reach providers through whichever channel works best.

Confirming delivery and resolving failed outreach

Delivery confirmation matters for HEDIS workflows. When a fax number is outdated or a Direct address is inactive, plans often don't discover the failure until weeks later. Managed delivery services actively resolve failures rather than simply report them, ensuring gap notifications reach someone who can act.

How clinical and supplemental data shape HEDIS performance

Understanding the difference between data types clarifies why some gaps remain stubbornly open.