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Home / Unified Payer Platform / Pay for Quality

Tying Revenue to Quality

In order to compete in a post-reform world, government-sponsored plans are faced with the dual requirements of managing costs and revenue in an integrated manner. Government-funded plans must be more focused on the health acuity of their members in order to maximize revenue on the population they manage. Quality has become a financial imperative as more dollars are tied to quality initiatives, such as HEDIS and Star programs.

Risk-based models have moved beyond Medicare and into Medicaid and public exchanges, providing additional complexity amid accelerating growth in risk-based plans. However, legacy systems were not built for this shift to value-based healthcare.

MedHOK’s Pay for Quality components form an end-to-end solution to meet all of the quality performance mandates, including year-round tracking of HEDIS, Star, Medicare Part C and D, Medicaid and other care gaps and quality measures. MedHOK empowers plans and providers to track quality performance throughout the year and run remediation campaigns to improve quality performance and revenue, thereby improving the bottom line.


Year-Round Care Gaps Management

Manage and close care gaps throughout the year to drive continued quality improvements

Complete Hierarchical Visibility

Realize full visibility across all levels of the organization, including lines of business, departments, members, and providers


Fully Integrated with Care Applications

Real-time data from continuum of care applications drive seamless quality management

Pay for Quality

Monitor, track, and improve quality performance by creating an ecosystem of best practices.

Click each heading below to learn more about the Pay for Quality components of the MedHOK Unified Payer Platform.

The HEDIS component of the MedHOK Unified Payer Platform is a comprehensive end-to-end solution that supports all aspects of commercial, Medicare and Medicaid lines of business for both administrative and hybrid measures. As opposed to most other vendors offering HEDIS® solutions, MedHOK has designed its solution to be business user configurable and clients have total control of the solution. After integration and implementation, clients can choose to run HEDIS® as often as they like to target, monitor, and remediate care gaps year-round. MedHOK holds full National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) Software Certification™.

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MedHOK’s comprehensive Star Analytics solution allows plans to monitor and track Part C and D measures as well as all HEDIS, CAPHS, HOS and administrative measures. A Star Improvement dashboard displays previous, current and target Star ratings, and measures campaign details. The Dashboard allows the user to view how well the plan is performing by contract level, plan type (MA, PA-PD or PDP), domain, C vs. D, and weight value. A custom tab lets plans look just at scores targeted for improvement.

An Action Center allows plans to view details of individual STAR measures and history, as well as document remediation/improvement activities. Plans can set desired performance thresholds and view different categories of the population relevant to that measure such as total, compliant, noncompliant, and minimum needed to reach goal.

Star Analyticis is integrated with Care Gaps to allow for remediation of Star measures via member and provider outreach. Health plans can initiate campaigns using the HEDIS engine to close care gaps. Campaigns are designed grouping related measures to maximize the outcome on multiple related measures with minimal member and provider impact.

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MedHOK’s Gaps in Care Management and Star Analytics help health plans excel in a value-based world. These solutions support drug and medical clinical measures, survey measures, and administrative measures to help plans remediate care gaps and improve member satisfaction in all lines of business. Ultimately, this results in better healthcare management and positions plans for higher ratings and corresponding reimbursements.

Plans and providers use the solution to improve quality ratings and therefore revenue coming to plans or at-risk provider groups. Campaigns and initiatives are developed and tracked that identify the target population for intervention, provide outreach to members/providers in support of remediation, and track progress against benchmarks and targets to achieve goals. Plans and providers track quality performance throughout the year and run remediation campaigns to improve quality performance and revenue.

Care Gap Management provides unparalleled opportunities to analyze monitor and remediate care gaps throughout the year, thereby reducing year-end fire drills associated with quality measure performance. MedHOK has an embedded NCQA HEDIS®-certified engine as well as other performance measures, including identification and stratification measures, Medicare Star, PQA® drug measures, ACO, NCQA Pay for Performance, and client-configured algorithms based on data resident in the MedHOK system.

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Medicare, Medicaid, and even commercial plans are being asked to aim for quality excellence as part of contracting with the public and private sector. Thus, quality outcomes become an important part of maintaining and growing revenue as well as containing costs. MedHOK’s Pay for Performance component provides the ability to directly reward providers for performance based on well-established and certified measures.

  • NCQA-certified Pay for Performance measures
  • Ability to design client-specific Star and HEDIS® performance pay for quality programs to enhance specific Star or Medicaid quality measures
  • Robust reporting and dashboard to measure progress by measure and provider

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MedHOK’s Risk Adjustment/RADV component offers an end-to-end risk adjustment solution aimed at accurate assessment, improvement and reporting of diagnosis-based capitation factors that drive risk score calculation systems. This facilitates efficient and effective submission of risk adjustment data and drives maximum appropriate reimbursement from Medicare and other payment agencies. Health plans can conduct mock audits or prepare for CMS RADV and other audits, in addition to proactively gathering medical chart review documentation to substantiate risk score submissions.

  • Creates CMS proprietary RAPS file for submission to CMS systems
  • Monitors required RAPS files to CMS’ FERAS and RAPS systems
  • Comprehensive work flow ensures swift remediation of any file and record errors, including updating key fields to ensure acceptance and HCC credit
  • Promotes quality outcomes by identifying high-risk members with chronic conditions to tie to Star and Care Gap closure
  • Analyzes incoming information for potential expiration (falloff of codes)
  • Estimates aggregate plan risk scores based on certified RAPS/MORs for future payment cycles as well as falloffs and opportunities
  • Estimates accrual revenue and future year revenue
  • Produces a random sample consistent with CMS methodology for mock audits
  • Intakes official CMS RADV audit universe for fulfillment
  • Adds critical eligibility, provider, and clinical information to each audit sample or CMS audit

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MedHOK’s Process Improvement/Root Cause Analysis functionality runs across the platform. MedHOK is able to trace the origins of a problem so that corrective measures can be put in place to ensure future success and alleviate identified problems.

  • Systematic workflow approach for identifying and reviewing opportunity and preventable issues for remediation
  • Standardized categorization of true root cause is captured for effective reporting
  • Comprehensive data capture allows for detailed reporting, including declaring if the identified problem presents an opportunity for process improvement or if the problem was preventable; root cause and source; and case workers’ detailed notes
  • Internal SLAs at various stages, with alerts and dashboard, to ensure timely investigation and resolution
  • Attachments can be uploaded as part of each case to track original issue, departmental remediation activities, resolution documents (e.g., test claims), and tracking of remediation activities (Adjust/reprocess/redistribute all impacted documentation/claims/checks, etc.)
  • Audit all actions taken as part of the RCA to ensure all providers and outbound items were accurately and sufficiently addressed and completed

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Compliance and Quality Take Center Stage

Efforts to transform to a value-driven healthcare system are well under way with the Centers for Medicare and Medicaid Services (CMS) leading the charge. As a result of healthcare reform, health plans and all risk-bearing entities will continue to experience the compounding impact of compliance as quality and risk requirements expand the definition of compliance and quality.

This webinar, presented by MedHOK’s Chief Strategy and Compliance Officer, Marc S. Ryan, will provide an overview of the latest changes with regard to compliance, audit, and quality in the Medicare Advantage program. 

Webinar Registration