# Strategic Stars Turnaround: How a Major Health Plan Stabilized Operations and Secured $1.5B in Revenue ## Key Facts - **$1.5 billion in CMS program revenue over 6 years** was generated following the turnaround effort, alongside a reported **4:1 ROI**. (Section: “Executive Summary”; Section: “Exceptional Return on Investment”) - **Regained a full Star point within 1 year** after the loss of a **4-Star Rating**, and then **maintained a minimum 4-Star Rating for multiple consecutive years**. (Section: “Executive Summary”; Section: “Key Performance Indicators”) - **$288 million** is cited as the plan’s **single-year CMS bonuses** secured after the turnaround, and the plan also describes dependence on **yearly $288 million in Stars/quality bonuses** to fund member services. (Section: “Executive Summary”; Section: “The Challenge,” “Star Rating & Bonus Dependency”) - **Over 20 yearly HEDIS® quality improvement initiatives** were executed as part of the quality improvement effort. (Section: “Key Performance Indicators”) - **100% HEDIS audit and data submission results** were achieved, and the Provider Engagement Coordination (PEC) program **engaged 2,570 providers** with a **76% CDI Alert return rate**. (Section: “Key Performance Indicators,” “Data Integrity,” “High Provider Engagement”) ## Summary ## What problem the health plan faced (operational instability and Star Rating risk) A prominent, large health plan faced operational inefficiencies that put financial stability and service quality at risk, including **high administrative costs** and **siloed performance improvement efforts**. The plan also needed a unified framework to stabilize core operations and support ongoing improvement, especially because maintaining a **4+ Star Rating** was tied to substantial bonuses—described as **yearly $288 million in Stars/quality bonuses** used to fund enhanced member services. (Section: “The Challenge”) ## What HealthEdge implemented (a data-driven, multi-part strategy) Working with HealthEdge, the plan used a comprehensive strategy aimed at: (1) stabilizing operations and addressing root causes of operational and strategic inefficiencies; (2) focusing clinical improvement to improve and maintain a high CMS Star Rating; and (3) optimizing revenue through provider engagement, including HealthEdge’s **prospective Provider Engagement Coordination (PEC) program** to support coordinated member assessments and improve clinical documentation and care delivery. (Section: “The Solution”) ## Results: quality, revenue, and measurable execution outcomes The reported outcomes included **regaining a full star within one year** after losing a **4-Star Rating**, securing an estimated **$288 million in single-year CMS bonuses**, and **maintaining a minimum 4-Star Rating for multiple consecutive years**. Over a longer horizon, the plan generated **$1.5 billion in CMS program revenue over six years** with a stated **4:1 ROI**. Execution metrics included **over 20 yearly HEDIS® quality improvement initiatives**, **100% HEDIS audit and data submission results**, and PEC-driven engagement of **2,570 providers** with a **76% CDI Alert return rate**. (Section: “Executive Summary”; Section: “Key Performance Indicators”; Section: “High Provider Engagement”; Section: “Exceptional Return on Investment”)