Closing the Gap: Leveraging Hybrid Records to Propel Medicare Advantage Plans to 5 Stars

Achieving a 4.5-Star rating is a major accomplishment for any Medicare Advantage health plan. But moving from 4.5 to 5 Stars is a different challenge altogether.

Only a small percentage of plans ever get there. Recent data from the Centers for Medicare and Medicaid Services (CMS) shows that fewer than 10% of Medicare Advantage contracts achieve a 5-Star rating in a given year, making it one of the most difficult thresholds in the program to reach.

Key Takeaways

• The 4.5-to-5-Star gap is a data problem, not a care problem. At the highest performance levels, missed documentation — not missed care — is the primary driver of lost Star Rating points.
• Hybrid records are the decisive variable. Combining administrative claims with clinical documentation creates the complete member picture that HEDIS requires for accurate measure credit.
• Provider friction is a solvable bottleneck. Targeting high-impact providers, simplifying record requests and reducing duplication directly improves submission rates and data completeness.
• MRR timing is unforgiving. Plans that automate ingestion and validation earlier in the cycle recover more records — and more numerator opportunities — before the window closes.
• Precision tooling matters at 5 Stars. Integrated HEDIS engines like Quality360® reduce variability in abstraction, surface gaps earlier and keep data audit-ready, making the difference in a margin-thin rating environment.

Why is the Final Half-Star the Hardest for Payers to Earn?

At such an advanced level, most health plans have already addressed obvious gaps. What remains are incremental improvements that require far greater precision, particularly in how clinical data is captured, validated, and submitted.

The financial stakes are just as significant. According to the Kaiser Family Foundation, health plans that reach 5 stars unlock year-round enrollment flexibility and higher Quality Bonus Payments, often translating into millions in additional revenue and meaningful competitive advantage.

The progression from 4.5 to 5 Stars becomes exponentially more difficult because performance is already tightly optimized across most measures. But to improve ratings from 4.5 to 5 Stars, payers should know:

• Small numerator gains can determine overall rating movement
• A limited number of members can materially impact outcomes
• Missed documentation (not missed care) becomes the primary driver of performance gaps

Plans operating at this level are no longer solving for broad improvement. They are solving for precision in data capture and submission, particularly during Medical Record Review (MRR).

What is the “Golden” Hybrid Record? Where 5-Star Performance Is Won or Lost

At the center of that effort is the “golden” hybrid record: a complete, accurate representation of a member’s care that bridges administrative claims and clinical documentation. For high-impact HEDIS measures like Comprehensive Diabetes Care and Controlling High Blood Pressure, claims data alone rarely tells the full story.

Consider this common scenario: A member receives appropriate care during a provider visit, but there is no claim to support the compliant data. From a HEDIS standpoint, that care does not count. When multiplied across a member population, small documentation gaps translate into measurable performance loss.

To succeed, there are two key areas that can drive the greatest impact.

1. Reduce Provider Friction to Improve Data Capture

Strong MRR performance depends on provider participation—and that is often where plans encounter resistance.

Providers are already managing significant administrative burden. According to the American Medical Association, physicians spend nearly two hours on administrative work for every hour of patient care. Additional record requests during HEDIS season can quickly create friction.

Plans that consistently perform well take a more targeted approach:

• Prioritizing high-impact providers based on member volume
• Streamlining record request workflows to reduce duplication
• Providing clear, concise guidance on documentation requirements

The goal is to make it easier for providers to participate without adding unnecessary burden. When that friction is reduced, submission rates improve and data quality follows.

2. Streamline Record Collection in a Compressed Timeline

MRR operates within a narrow window. Delays early in the process limit what information can be recovered later.

Relying on traditional approaches to record collection—which include manual chart retrieval, disconnected systems, and batch processing—can cause payers to struggle to keep pace with the volume and speed required. Leading plans are focusing on more connected, real-time approaches:

• Automated record ingestion from multiple data sources
• Continuous validation of incoming clinical data
• Centralized data environments that create a single source of truth

Integrated solutions and services, such as those offered by HealthEdge®, are helping abstractors identify relevant clinical elements more efficiently and consistently.

Closing the Final Gap: Where 5-Star Performance Is Decided

For plans already operating at a 4.5-Star level, the path to 5 Stars comes down to execution during MRR. At this stage, performance depends on:

• Identifying the members most likely to impact measure outcomes
• Capturing complete and accurate clinical documentation
• Validating and submitting data within a compressed timeline

Quality360 from HealthEdge®, an NCQA-certified HEDIS engine, supports this level of precision by integrating clinical and claims data, automating record retrieval workflows, and providing real-time visibility into measure performance.

Quality360® is built to support the realities of HEDIS season, where timing, accuracy, and completeness all matter. It centralizes clinical and claims data into a single, normalized dataset, allowing teams to identify measure gaps earlier and prioritize the members most likely to impact outcomes. Integrated abstraction workflows guide chart reviewers to the exact data elements needed for each measure, reducing variability and rework.

At the same time, automated record ingestion and validation help ensure that supplemental data and medical records are complete, compliant, and audit-ready before submission, which minimizes the risk of missed numerator opportunities late in the cycle.

This level of control and visibility allows plans to focus effort where it matters most: on the relatively small number of records that ultimately determine whether the gap to 5 Stars is closed.

Why the Time to Act is Now

If your organization is looking to strengthen its MRR strategy and close the gap to 5 Stars, now is the time to evaluate how your current approach is performing.

Learn how the Quality360® HEDIS® Engine, within the integrated HealthEdge risk adjustment and quality solution, can help payers improve data accuracy, streamline workflows, and drive measurable improvements in Star Ratings performance.

See how to advance Risk Adjustment & Quality strategy at your health plan.

Frequently Asked Questions

What percentage of Medicare Advantage plans achieve a 5-Star rating? Fewer than 10% of Medicare Advantage contracts achieve a 5-Star rating in a given year, according to CMS data — making it one of the most difficult thresholds in the program to reach.

What is the “golden” hybrid record in Medicare Advantage? The “golden” hybrid record is a complete, accurate representation of a member’s care that bridges administrative claims and clinical documentation. For high-impact HEDIS measures like Comprehensive Diabetes Care and Controlling High Blood Pressure, claims data alone rarely tells the full story — the hybrid record closes that gap.

Why is the jump from 4.5 to 5 Stars so difficult? At the 4.5-Star level, most health plans have already addressed obvious gaps. Performance is already tightly optimized across most measures, so what remains are incremental improvements that require far greater precision in how clinical data is captured, validated and submitted. Small numerator gains and a limited number of members can determine overall rating movement.

What happens when care is delivered but there is no supporting claim? From a HEDIS standpoint, that care does not count. When that scenario is multiplied across a member population, small documentation gaps translate into measurable performance loss — which is why building accurate hybrid records during Medical Record Review is so critical.

How does provider friction affect MRR performance? Physicians already spend nearly two hours on administrative work for every hour of patient care. Additional record requests during HEDIS season can quickly create friction, reducing provider participation and lowering submission rates. Plans that prioritize high-impact providers, streamline request workflows and provide clear documentation guidance see better data quality as a result.

What does Quality360® do to support 5-Star performance? Quality360® integrates clinical and claims data, automates record retrieval workflows and provides real-time visibility into measure performance. It centralizes data into a single, normalized dataset, guides abstractors to the exact data elements needed for each measure and ensures records are complete, compliant and audit-ready before submission.