Case Study: A Health Plan's Success Story — Oversight Program Revitalizes Health Plan Facing Operational Challenges

Health plans today face significant operational challenges, especially when scaling with advancing technology. Simplifying these complexities is essential for focusing on member health and organizational growth. This case study explores how HealthEdge partnered with a health plan client to overcome substantial operational and program hurdles for their new-to-market contracts, transforming their performance and financial trajectory.

The Challenge: Overcoming Key Operational Hurdles

The client, managing several new contracts, required a robust solution for core administration to address critical pain points across their operation. Without established oversight or scalable processes, the plan faced significant risks to its revenue and member services.

The primary challenges included:

• Revenue: The need to establish a strong payment and bonus trajectory to fund future member services and offerings.

• Oversight: A complete lack of established program or operational oversight.

• Operations: The necessity to scale and stabilize staffing, operational activities, and the overall customer experience.

• Reporting: An absence of timely and accurate reporting for key performance indicators (KPIs) and performance programs.

A Strategic Path to Success: HealthEdge's Two-Year Implementation

HealthEdge developed a targeted, two-year strategy to address these challenges and establish a foundation for long-term success. The approach focused on three measurable goals designed to deliver a significant impact on day-to-day operations and overall performance.

Goal 1: Achieving a 4-Star Rating and High-Quality Performance

The first objective was to achieve a high-quality performance rating within the first year. The Stars team collaborated with the HEDIS® (Healthcare Effectiveness Data and Information Set) team to define a supplemental and historical data strategy. By developing a Stars strategy and action plan and executing clinical initiatives with proven ROI, the plan was positioned to adapt to CMS standards and improve Star Ratings from the outset.

Goal 2: Enhancing Risk Score Accuracy

For the client's new Medicare Advantage plans, establishing accurate baseline member risk scores was critical.

• Year One: Focused on In-Home Assessments to capture comprehensive member health data.

• Year Two: Ramped up the Remote Clinical Documentation Improvement (CDI) program to improve the recapture of historical diagnoses. This process was enhanced by Risk Mitigation programs to audit provider charts for coding deficiencies and risks within the network.

Goal 3: Implementing Comprehensive Risk Adjustment Solutions

HealthEdge implemented a member-centric risk adjustment strategy to improve risk score accuracy. This involved a combination of prospective and retrospective solutions:

• Prospective Solutions: In-Home Assessments and an expanded Remote CDI program improved the capture of current and historical conditions.

• Retrospective Solutions: Retrospective chart reviews were conducted to ensure no diagnoses were missed.

• Risk Mitigation: Audits of provider charts identified coding deficiencies, with follow-up reports delivered to the plan to facilitate provider education and remediation.

The Outcome: Measurable Improvements and Significant Financial Gains

The strategic partnership yielded exceptional results, stabilizing operations and creating a strong financial and quality performance foundation. The health plan achieved significant improvements in revenue, risk score accuracy, and quality ratings, allowing it to better serve its growing membership.

Key performance outcomes include:

By working with HealthEdge, the health plan successfully turned the tide on its operational challenges. Together, we continue to drive operational stability, enabling the plan to maintain its focus on what matters most: the health of its members.