Real-Time Quality Performance for Health Plans
Quality measures move in days. Claims arrive in weeks or months. Quality-linked revenue protection rides on a window that closes before teams can see it.
The Window to Act Closes Before Teams Can See It
Health plans depend on HEDIS and CMS Star performance to protect quality-linked revenue. But for most plans, performance runs on claims data that lags weeks or months behind, with gaps surfacing after the measurement window has closed. As CMS shifts weight toward clinical and outcome measures triggered at discharge, the gap between claims-based workflows and what teams need is widening. Real-time care gap identification, clinical context, and provider coordination can close it.
Why Quality Performance Stays Reactive
Claims Arrive Too Late
Encounters show up in claims weeks to months after they happen, long after the measurement window has closed.
Measure Windows Are Days
CMS is shifting weight toward clinical and outcome measures triggered at discharge, with post-discharge quality action in days.
Revenue Rides on Stars
A drop from 4.5 to 3.5 stars can cut MA operating income by up to 40%, with similar stakes for Medicaid plans.
UM Levers Are Narrowing
Prior auth and UM act on single decisions. They can’t move the measures triggered between care settings.
If we had continued to practice the way we were, we wouldn’t have captured any of the withhold revenue. Quality IQ gave us real-time visibility into care gaps we were missing entirely and the tools to act before the window closed.
Chief Medical Officer
National Health Plan, Virginia Medicaid
$3.4M
Projected HEDIS revenue captured
$2.3M
Utilization savings
Quality IQ for Real-Time Quality Performance
Quality IQ enables real-time care gap identification the moment a member enters a HEDIS or CMS Star denominator through continuous ADT monitoring, with care gaps prioritized by urgency and consolidated into one worklist.
Additional Solutions for Real-Time Quality Performance
Discharge Intel
Discharge Intel gives quality and care teams the clinical context to make every post-discharge quality action count. AI-powered summaries distill 20+ pages of hospital discharge documentation into medications, diagnoses, follow-up requirements, and barriers to care delivered within 24 hours across 2,800+ hospitals and 3,600+ clinics. Criteria flagging surfaces med-rec opportunities tied directly to HEDIS and Stars.
Product Capabilities:
AI-powered clinical summaries distill 20+ pages of discharge documentation into what drives outcomes.
Delivered within 24 hours of discharge so teams can act in the window that protects quality measures.
EHR-agnostic across 2,800+ hospitals and 3,600+ clinics, no matter which system the facility uses.
Beers Criteria flagging surfaces medication-reconciliation opportunities tied to HEDIS and Stars.
Network Notify
Network Notify automates the data exchange that the Transitions of Care Star measure depends on. It addresses the two TRC components plans struggle with most at scale—admission notifications and discharge documentation to the attributed PCP within two business days—through real-time triggering on qualifying inpatient encounters and direct secure message delivery. EHR-agnostic and audit-ready for NCQA documentation requirements.
Product Capabilities:
Real-time triggering on qualifying inpatient encounters identifies TRC denominator events as they happen.
Admission notifications reach the attributed PCP automatically, within the 2-business-day TRC window.
Discharge documentation is delivered via direct secure message within 72 hours — EHR-agnostic, not by fax.
Audit-ready documentation aligned with NCQA technical specs supports a triple-weighted Star measure family.
PAC Management IQ
PAC Management IQ extends quality visibility into post-acute settings where readmission risk concentrates. Powered by the leading system of record for post-acute care, it surfaces live SNF and long-term care clinicals, identifies members rising in readmission risk during the stay via AI-driven Predictive Return to Hospital scoring, and signals when a member is ready for the next setting, protecting PCR, a triple-weighted Star measure..
Product Capabilities:
Live SNF and long-term care clinicals during the stay, not claims generated weeks after it.
AI-driven Predictive Return to Hospital (pRTH) scoring identifies members rising in readmission risk.
Discharge readiness signals support timely transitions, protecting PCR — a triple-weighted Star measure.
Closes the post-acute blind spot for the populations driving the most quality-linked revenue exposure.
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