Workflow — HEDIS / Stars Chart Abstraction

Cut HEDIS abstraction labor by 80% during measurement season.

Member roster, measure specs, EMR access (or paper-record requests) → A1c values, BP readings, screening dates, and other measure-specific data points abstracted per HEDIS technical specs (NCQA). Direct into Inovalon, Cotiviti, or Optum HEDIS engines; audit-ready hybrid sample. Replaces HEDIS abstractor labor at $2–$8 per chart during measurement season at a fraction of the per-chart cost.

Take the AI Assessment Get a Per-Chart ROI Model

$2–$8

Per chart at HEDIS abstractors during measurement season

Spring

Concentrated measurement season window

60–85%

Routine abstraction off the desk after AI cutover

What This Replaces

The HEDIS Abstractor Surge Every Spring

The work the HEDIS abstractor does on every chart during measurement season — and the cost of leaving it there.

The labor

HEDIS / Stars chart abstraction today moves through HEDIS abstractors during the spring measurement season — typically a mix of in-house quality teams and seasonal-contract abstractors at Inovalon, Cotiviti, Optum, GeBBS Healthcare Solutions, EXL Healthcare, and Episource. Per-chart cost runs $2–$8 fully loaded during measurement season. A mid-size MA plan with hundreds of thousands of members across multiple regions hires hundreds of seasonal abstractors to clear the chart-pursuit population by NCQA submission deadlines.

The cycle time

Standard HEDIS abstraction season runs January through May with NCQA submission deadlines around June. Plans burn through chart pursuit (provider chart requests, abstraction, hybrid-sample QA) at a frenzied pace because every chart that doesn't clear the abstraction line in time is a measure-rate hit and a Stars-rating impact. Plans with thousands of charts in flight rely on hybrid-sample audit-readiness — and audit findings on hybrid-sample errors compress the timeline further.

The Workflow

Input · Analysis · Output

What goes into HEDIS abstraction, what we do to it, and what shows up in the HEDIS engine.

Input

Member roster + measure specs + EMR

Member roster with eligibility data
NCQA HEDIS measure specifications
EMR access (Epic, Cerner, athena) or paper-record requests
Lab data (A1c, lipid panels, etc.)
Vital signs (BP readings, BMI)
Screening dates (mammo, colorectal, cervical)
Vaccination records

Analysis

Locate, abstract, validate

Per-measure data-point identification
Numerator-event verification per HEDIS measure
Denominator-eligibility validation
Date-range and look-back-period compliance
Hybrid-sample audit-readiness scoring
Per-measure exclusion identification
Confidence score per finding; exceptions to abstractor queue

Output

HEDIS data into the engine

Inovalon (REST APIs)
Cotiviti (REST APIs)
Optum HEDIS (documented integration)
Audit-ready hybrid sample
NCQA-format HEDIS submission file
Per-measure rate dashboard
Per-chart audit trail with HEDIS-citation basis

Side by Side

HEDIS Abstraction Today vs. With Last Rev

The numbers that matter: cycle time, per-chart cost, accuracy, and Stars-rating defensibility.

Dimension	HEDIS Abstractor (Seasonal)	Last Rev HEDIS Abstraction
Cycle time, chart receipt to abstracted	20–60 minutes per chart	2–5 minutes per chart
Per-chart unit cost	$2–$8 per chart at season abstractors	Per-chart, benchmarked at 25–45% of abstractor unit cost
Surge handling during measurement season	Hire hundreds of seasonal abstractors, training overhead	Elastic by design — no headcount ramp
HEDIS-spec consistency	Variable — abstractor judgment, drift on uncommon measures	NCQA HEDIS technical specs applied identically per chart
Hybrid-sample audit-readiness	Audit-prep work post-abstraction	Per-chart audit-readiness scored at abstraction time
HEDIS engine integration	Manual / batch upload to Inovalon / Cotiviti / Optum	Direct via documented Inovalon / Cotiviti / Optum APIs
Audit log per finding	Abstractor notes, no per-data-point lineage	Source EMR encounter + HEDIS-spec citation + confidence per data point

How It Works

From Member Roster to NCQA-Ready Submission

Five steps. Every one logged. Every one reversible if your confidence threshold isn't met.

Submission Lands

Member roster with eligibility data, NCQA HEDIS measure specifications, and EMR access (Epic, Cerner / Oracle Health, athenahealth) or paper-record requests for member-pursuit charts. Lab data, vital signs, screening dates, and vaccination records pulled into the same review.

Extraction & Classification

Per-measure data-point identification per the NCQA HEDIS technical specs. Numerator-event verification. Denominator-eligibility validation. Date-range and look-back-period compliance. Hybrid-sample audit-readiness scoring. Per-measure exclusion identification.

Validation Against HEDIS Spec

Findings validated against the NCQA HEDIS technical specs for the measurement year and the plan's HEDIS-abstraction playbook. Anything below your confidence threshold per finding is routed to the abstractor / quality-team review queue — final HEDIS submission remains with the regulated entity.

Push to HEDIS Engine

HEDIS measure-data into Inovalon, Cotiviti, or Optum HEDIS engines via the documented integration. Audit-ready hybrid sample assembled. NCQA-format HEDIS submission file ready for plan review and NCQA submission. Per-measure rate dashboard updated.

Audit Log Persisted

Every measure-data-point identification, numerator-event verification, and exclusion finding logged with the source EMR encounter, HEDIS-spec citation, model version, and confidence score. NCQA-audit-ready and yours.

Compliance & Defensibility

Built to Meet the Quality Bar HEDIS / Stars Operations Already Run On

NCQA HEDIS technical-spec conformance

NCQA HEDIS measure specifications for the current measurement year tracked. Per-measurement-year spec versioning preserved in the audit log. Updates to specs flow into the validation engine within days of NCQA publication.

Hybrid-sample audit-readiness

NCQA hybrid-sample audit standards respected. Per-chart audit-readiness scored at abstraction time so plans go into NCQA audits with structured evidence rather than abstractor reconstruction.

CMS Stars and state-DOI defensibility

When CMS reviews Stars-rating-related data or state DOIs review HEDIS-grounded contract metrics, the audit log produces what was abstracted, which HEDIS spec applied, and what the source-encounter basis was. Cleaner chain of custody than the seasonal-abstractor reconstruction.

PHI / HIPAA / HITRUST posture

HEDIS chart data contains PHI under HIPAA. Deployable in your VPC or our SOC 2 / HITRUST / HIPAA-aware environment. Encryption in transit and at rest; retention policies tied to your NCQA recordkeeping rules and HIPAA-specific recordkeeping requirements.

Common Questions

What MA Plans, Medicaid Plans & ACA Plans Ask About HEDIS Abstraction

Those are the HEDIS engines where measure rates and Stars data live. The competitor on this page is the HEDIS abstractor labor that does the actual chart-extraction work — typically seasonal abstractors at $2–$8 per chart at Inovalon, Cotiviti, Optum, GeBBS Healthcare Solutions, EXL Healthcare, or Episource. We undercut that labor cost, integrate directly into your existing HEDIS engine, and deliver measure-data extracts into the system of record.

Per-chart AI abstraction costs are largely fixed regardless of population, so 100% chart pursuit becomes feasible during measurement season without the seasonal-abstractor headcount ramp. Plans process the chart-pursuit population in days-to-weeks rather than months. Hybrid-sample audit prep happens at abstraction time rather than in a separate pre-audit cycle.

Our pilot success threshold is per-data-point extraction accuracy at parity with or above your incumbent abstractor process, measured on the same shadow-data sample of historical charts. Anything below your defined confidence threshold per finding is routed to the abstractor / quality-team review queue — your call which queue, ours or yours.

Per-chart audit-readiness is scored at abstraction time. NCQA hybrid-sample audit standards are encoded as configurable rules — when a chart's data points are likely to land in the hybrid sample, the workflow surfaces the audit-evidence package with the source encounter / note citation. Audit prep happens at abstraction time, not in a separate pre-audit cycle.

Paper-record pursuit (provider chart requests, fax intake, mailed charts) flows through the same pipeline as EMR data — the workflow handles document classification and per-measure data-point extraction regardless of source. Provider-pursuit cycle time often drops because the chart workflow goes straight to abstraction once received.

Yes — through the documented integration surface each platform supports. Epic via App Orchard / FHIR APIs; Cerner / Oracle Health via FHIR APIs; athenahealth via REST APIs; Inovalon, Cotiviti, and Optum HEDIS via documented integration patterns. Your IT, clinical, and quality teams review and approve service accounts. We do not require platform-side custom development.

HEDIS pilots typically run 6–8 weeks: 1–2 weeks of integration and per-measure spec mapping with the HEDIS team, 4 weeks of shadow-mode running on real charts with no HEDIS-engine writes, 1–2 weeks of supervised cutover on a constrained scope (one measure category, one product line). Production rollout is staged after the pilot meets your accuracy and HEDIS-management sign-off.

We benchmark against your current per-chart cost — typically $2–$8 at season abstractors. Our target is 25–45% of that per-chart cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs (NCQA-audit defensibility), not hourly billable rates.

Two Ways to Start

Take the AI assessment for a structured read on HEDIS abstraction feasibility. Or talk to us if you already know spring-measurement-season abstractor labor is the largest seasonal cost on your quality-program budget.

Self-serve · 8 minutes

Take the AI Assessment

A short structured assessment that maps your seasonal HEDIS volume, HEDIS engine, and current abstractor arrangement to AI feasibility and ROI.

Talk to a specialist

Get a Per-Chart ROI Model

Send us your seasonal HEDIS volume, your HEDIS engine, and your current abstractor arrangement. We'll come back with a per-chart unit-cost comparison and a 6–8 week pilot plan in 5 business days.

Other Workflows

More Healthcare Admin Workflows We Replace

The same approach, applied to the other document-heavy labor lines on your healthcare-admin budget.

HCC Coding Review

Progress notes, discharge summaries → HCC capture per MEAT criteria. Submission to CMS RAPS/EDS.

Inpatient / Outpatient Coding

H&P, op reports, discharge summaries → CPT, ICD-10, MS-DRG. AAPC / AHIMA-aligned coding.

Prior Authorization

Physician orders + clinical notes → InterQual / MCG match, payer-portal submission, status tracking.

Charge Capture & Reconciliation

Charge tickets, EMR docs, supply utilization → undocumented / late / missed charges identified.