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Ensure Premium Quality To Drive Revenue Realization

Quality is at the center of value-based healthcare.  The member is at the center of quality. Quality programs must be member-centric and built around regulatory guidance and requirements. Healthcare organizations that are based on a systems infrastructure that is still oriented to the vertically-oriented legacy claims processing fee-for-service model are struggling to make this transformation. Quality is measured in terms of outcomes which shift service focus and measures to a horizontally oriented continuum of care focus. Healthcare organizations need a powerful unified system to make this transition.

Many healthcare oganizations are trying to bake the value-based healthcare and compliance pie, one piece at a time. Addressing individual components of the complex health plan service delivery model, these healthcare organizations end up with multiple disparate systems that lack integration and cohesive, meaningful and actionable data. To make the transformation to value-based healthcare, healthcare organizations need to bake the whole pie and consume it one piece at a time. 

MedHOK’s Unified Payer Platform provides full range of quality solutions that enable member-centered premium quality care, compliance adherence and quality measurement. MedHOK quality solution include HEDIS®, Star Quality Measures, Care Gaps, Risk Adjustment and Data Validation, Process Improvement/Root Cause analysis and others. Providing automated structured workflows fully integrated between solutions components, MedHOK enables a unified approach to ensuring quality, compliance and value delivery. MedHOK's Unified Payer Platform provides everything you need to succeed in value-based healthcare and compliance. It's all right here. 

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Comprehensive HEDIS® solution fully integrated with structured workflow applications ensuring real-time compliance adherence.


The #1 Rated Health Plan in the U.S. Uses MedHOK's Unified Payer Platform.


Identify and remediate gaps in care to drive improved quality ratings and revenue realization.

Quality Components

MedHOK delivers a broad range of quality modules that improve compliance, operational efficiency, revenue realization, quality outcomes and enable the transformation to value-based healthcare.

Learn more about the Quality components in MedHOK's Unified Payer Platform by clicking the titles below.

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 filings 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™.



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 measure 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, history, and 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 to reach goal.

Integrated with Care Gaps to allow for remediation of Star measures via member and provider outreach. 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.




MedHOK’s Gaps in Care Management and Star Analytics helps 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. This ultimately 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, 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 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.



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



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. 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 a 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



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



White Paper

Focus on the Member: The Premise for Value-Based Healthcare

Value-based healthcare requires a focus on the Member -- quite a shift from the provider-centric, transaction-focused models Payers are familiar with. This paper discusses how a focus on the Member will result in better quality, care, and outcomes.

Fill out the form to the right to download the paper now.