Case Study: Health Plan Revitalization - A Strategic Oversight Program for a Leading Health Plan

For health plans, navigating the complexities of modern healthcare technology and operations is critical for sustainable success. HealthEdge implemented a comprehensive oversight program for a health plan with new-to-market contracts, focusing on achieving a high Star Rating, enhancing risk score accuracy, and deploying robust prospective and retrospective solutions.

One client entered the market with new contracts and faced considerable hurdles in establishing a robust operational framework. The health plan required a sophisticated technology solution to simplify its landscape, allowing its team to concentrate on member care, regulatory compliance, and strategic growth.

What were the primary operational and revenue challenges?

The health plan faced significant barriers in revenue optimization, operational scalability, program oversight, and data reporting. To achieve sustainable growth, the health plan needed a strategic partner to establish a strong payment trajectory and secure bonus revenue to fund future member services.

According to the initial assessment, the primary challenges were concentrated in four key areas:

• Revenue Optimization: The health plan needed to establish a strong payment trajectory and secure bonus revenue to fund future member services and expand its offerings.
• Operational Scalability: Immediate needs included stabilizing staffing, scaling operational activities efficiently, and enhancing the overall customer experience.
• Program Oversight: A formal program and operational oversight structure was non-existent, creating a barrier to effective governance and performance management.
• Data and Reporting: The absence of timely and accurate reporting across key performance indicators (KPIs) and performance programs hindered data-driven decision-making.

How did HealthEdge optimize health plan performance and risk scores?

HealthEdge collaborated with the health plan to architect a multi-faceted strategy designed for rapid, measurable impact, focusing on Star Ratings, risk score accuracy, and comprehensive risk adjustment solutions. The HealthEdge solution was built around three core goals to directly address the identified operational deficiencies:

Goal 1: Achieve a 4-Star Rating and High-Quality Performance in Year One

The HealthEdge Stars team partnered with the health plan’s HEDIS® team to define and implement a supplemental and historical data strategy. A detailed Stars strategy and action plan were developed in Q4, prior to the measurement year, focusing on clinical initiatives with proven return on investment (ROI). This proactive approach ensured gap closures were executed effectively during the first half of the measurement year to drive immediate success in clinical measure performance.

Goal 2: Increase Risk Score Accuracy and Improve CDI Return Rates

With two new Medicare Advantage plans, the primary objective for the first year was to establish accurate baseline member risk scores. In the second year, the strategy evolved to scale the Remote Clinical Documentation Improvement (CDI) program to improve CDI return rates and drive the recapture of historical diagnoses and conditions. Concurrently, HealthEdge implemented Risk Mitigation programs to audit provider charts, systematically identifying and addressing coding deficiencies across the network.

Goal 3: Implement Comprehensive Prospective and Retrospective Solutions

A member-centric risk adjustment strategy was deployed to fundamentally improve risk score accuracy. The initial year focused on member engagement through specialized treatment programs, while the second year saw the expansion of the Remote CDI program to enhance diagnostic recapture rates. Retrospective chart reviews were conducted to identify previously missed conditions, and follow-up reports were delivered to facilitate targeted provider education and remediation.

What were the financial and operational results of the revitalization program?

The strategic partnership delivered significant, quantifiable improvements in financial performance, quality ratings, and operational stability. HealthEdge enabled the health plan to overcome foundational challenges and establish a trajectory for long-term success.

The strategic oversight program yielded the following data-driven results:

• Substantial Revenue Growth: The health plan achieved an estimated $2.1 million in CMS Program Revenue within the first year. This growth was driven by boosting CDI alert completion rates to 40% by the second year and capturing an average of 1.2 Hierarchical Condition Categories (HCCs) per alert.
• Exceptional Quality Ratings: The health plan achieved and has since maintained a 4.5 Star Rating, including in its first rated year. This high performance resulted in an estimated $4.8 million single-year CMS bonus, which was reinvested to support growing membership.
• Enhanced Risk Score Accuracy: The targeted initiatives led to a 20% improvement in the health plan’s risk score over a two-year period, establishing a new financial benchmark that enables shared savings.
• Improved Member Experience: A strategy implemented to address CAHPS® survey performance resulted in the health plan achieving a 4+ Star Rating on over seven individual 4-weighted CAHPS® measures.
• Operational Stabilization: By introducing robust operational tracking, root cause analysis, and transparent metric reporting, HealthEdge successfully stabilized operations and improved customer service.

Frequently Asked Questions

Q: How does a Remote CDI program improve health plan revenue?

A: A Remote Clinical Documentation Improvement (CDI) program enhances diagnostic recapture rates by identifying historical diagnoses and conditions, which improves risk score accuracy and ultimately drives increased CMS program revenue.

Q: What strategies can new health plans use to achieve high Star Ratings in their first year?

A: New health plans can achieve high Star Ratings by partnering with technology providers to implement proactive supplemental and historical data strategies, executing gap closures early in the measurement year, and focusing on clinical initiatives with proven ROI.

Q: Why is risk score accuracy critical for Medicare Advantage plans?

A: Risk score accuracy establishes an accurate financial benchmark that reflects the true health status of a member population, enabling the health plan to secure appropriate CMS funding, achieve shared savings, and deliver cost-effective care.