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Optimizing Medical Chart Review Sample Size Reduction with a Monte Carlo Simulation (303000)

Keywords: Monte Carlo Simulation, Sample Size, Medical Chart, HEDIS, Risk Control, Lower-Bound

Medical chart review for the annual HEDIS process places a substantial burden on health plans, as it requires clinical professionals to manually retrieve large numbers of charts. A sample size of 411 per measure per Medicare contract is required by NCQA, unless a health plan can demonstrate that a reduced sample does not compromise the statistical power. A Monte Carlo simulation was developed to assess the risk of reporting lower HEDIS rates with a smaller sample. Using HEDIS rates from 2011, simulations were done for full and reduced sample sizes (a=0.05). Comparing the resulting rates, the reduced sample was requested for contracts where no risk was found. A lower-bound assumption methodology was developed to validate the model. Evaluating the scenario where a reduced sample yielded a low rate, we tested if using a full sample would significantly improve this low result. This potential negative impact was only observed in a few cases. To further control the risk of the reduced sample, we incorporated a validation process as part of the assessment. The volume of charts reviewed was reduced by more than 21,000, with an estimated $630,000 savings in operation costs.