Health plans often face challenges due to limited resources, which hinder their ability to provide comprehensive care and support to their members. These limitations can include insufficient funding for innovative healthcare initiatives, limited access to specialized medical professionals, or constrained administrative capacity to efficiently handle complex member needs.

Our client needed more resources to focus on delivering quality care and achieving CMS performance incentives and bonuses. However, complex operational challenges prevented them from fulfilling this need, a common issue for many health plans.

As a result, our client struggled to meet the evolving demands of the healthcare landscape.

To tackle these challenges, our client wanted to explore strategies to optimize resource allocation and leverage technologies to reduce risk and enhance quality performance.

Working with our client, we created targeted strategies aimed at three primary goals:

Goal 1: Improve Star Ratings through Robust Reporting and Modeling

CMS Star Ratings significantly impact many aspects of a Medicare plan’s financial security, ability to recruit and retain members, provide quality care and cost reduction for members.  

To meet these objectives, we analyzed performance trends and projections, modeling a path to 4-Star Rating. This enabled a data-driven strategy to launch over 20 quality improvement initiatives in the first year. Additionally, we implemented proactive measures to enhance member outcomes and satisfaction, including targeted survey conditioning and engagement efforts.

Goal 2: Improve Risk Score Accuracy and Completeness

During the annual Retrospective Chart Review project, the staff deployed more than 10 internal resources and leveraged existing best-in-class vendor partnerships. This effort increased the completion rates of member In-Home Assessments, improving the accuracy and completeness of risk scores.

Goal 3: Improve Decision-Making through Better Data and Analytics

Leveraging our client's data, CMS files, and internal program participation information, UST HealthProof developed modeling to enable more informed decisions on programs deployment. An opportunity analysis of the plan’s population identified more viable targets for prospective and retrospective programs, focusing on high-risk members to optimize program outcomes and improve Return on Investment.

"Maintaining a 4+ Star Rating for three consecutive years, the plan showcased robust data management and strategic planning capabilities, resulting in significant financial and health-related improvements."

The plan demonstrated remarkable success, maintaining a 4+ Star Rating for three consecutive years since partnering with UST HealthProof. This achievement reflects a commitment to excellence and continuous improvement. With a year-over-year HEDIS® data retrieval rate exceeding 90% and an accuracy rate of over 99% in performance projections, the plan showcases robust data management and strategic planning capabilities.

Implementation of a comprehensive Risk Adjustment Reporting package yielded significant improvements in both financial and health-related outcomes. Targeted prospective In-Home Assessments achieved a 14% participation rate among new members, demonstrating proactive care management. Additionally, a coordinated strategic approach led to a 12.5% improvement in the historical chronic condition recapture rate, resulting in a 10% increase in risk scores over two years and an estimated $2.2 million in one-year CMS program revenue.

These results underscore the effectiveness of the plan's strategy in optimizing risk stratification data, documentation accuracy, and resource allocation, ultimately improving health outcomes and ensuring financial sustainability.

We are a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our solutions manage complex admin tasks, allowing our customers to prioritize members' well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.