Health plans today face growing challenges in running a successful operation, particularly with the rapid advancement of technology making scalability difficult. Simplifying technological complexities is crucial for health plans to focus on their employees and members.

Among the many complex issues health plans face, simplifying operational challenges is one that allows health plans to focus on their members.

UST HealthProof helped a client seeking a solution for core administration. The client had several new-to-market contracts and needed to overcome various operational and program challenges.

UST HealthProof partnered with the health plan to find an achievable path to see results quickly.

The team identified three goals that would address the plan’s pain points.

Goal 1: Achieve a 4-Star Rating and high-quality performance in the first year

The Stars team partnered closely with the HEDIS® (Healthcare Effectiveness Data and Information Set) team to define a supplemental and historical data strategy to drive immediate clinical measure success.

We strategized with the client to effectively reach their goals within two years and to establish a strong Star Rating within one year. We focused on the measurable goals that make a real impact on the day-to-day operations.  

The team developed a Stars strategy and action plan in the fourth quarter before the implementation and measurement year. They executed clinical initiatives with proven ROI for closing gaps during the first and second quarters of the measurement year.  

Goal 2: Realize increased risk score accuracy with In-Home Assessments in Year One and improve Remote CDI and return rates in Year Two

For a client with two new Medicare Advantage plans entering the market, the goal was to establish accurate baseline member risk scores through In-Home Assessments in year one. In Year Two, we ramped up our Remote CDI program and improved CDI return rates to drive historical diagnosis and condition recapture (gap closure). We also implemented Risk Mitigation programs to audit provider charts for coding deficiencies and risks within the network. We successfully achieved these goals within two years of implementation.

Goal 3: Implement comprehensive prospective and retrospective solutions

UST HealthProof implemented a member-centric risk adjustment strategy to improve risk score accuracy. In the first year, we focused on treating members through In-Home Assessments. In the second year, we expanded our Remote CDI program and increased CDI return rates to enhance the recapture of historical diagnoses and conditions.

We conducted retrospective chart reviews to ensure no conditions were missed and used Risk Mitigation programs to audit provider charts, identifying any coding deficiencies and risks. Follow-up reports were delivered to the plan to facilitate provider education and remediation. 

The health plan achieved an estimated $2.1 million in CMS Program Revenue within one year by boosting Clinical Documentation Improvement alert completion rates to 40% by the second year and averaging 1.2 Hierarchical Condition Categories (HCCs) captured per In-Home Assessment.

"The health plan was able to realize an estimated $2.1 million in one-year CMS Program Revenue through increasing Clinical Documentation Improvement alert completion rates to 40% by year two and averaging 1.2 HCCs captured per In-Home Assessment."

This increased operational performance led to a 20% improvement in the health plan’s risk score over two years. Using this risk score to establish the financial benchmark, the plan achieved shared savings. These benchmarks indicate that our client is on track to improve risk score accuracy across the board, leading to better health outcomes for members as well as cost savings for the health plan.  

The plan also achieved and maintained a 4.5 Star Rating, including the first rated year, resulting in an estimated $4.8 million single-year CMS bonus to invest back into its growing membership. Although the plan had not yet been rated on CAHPS® measures, we recognized the importance of CAHPS® surveys in CMS's efforts to enhance overall health and quality of care for members. We developed a strategy to immediately address CAHPS® ratings by implementing member experience and survey conditioning best practices with industry-leading vendor partners. We celebrated, following the plan's rating on CAHPS®, on achieving a 4+ Star Rating on over seven individual 4-weighted CAHPS® measures!

We successfully stabilized operations and improved customer service by introducing robust operational tracking, root cause analysis and reporting, and metric transparency. This resulted in enhanced risk score accuracy and financial improvement.  

Together, we continue to work toward operational stability so the plan can maintain its focus on the health of its members. 

We are a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS 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.

Disclaimer

The facts in this case were based on UST HealthProof goals and measures. At the time of publishing, these facts are up to date.