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Quality: Focus on Member Experience

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


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 Quality Management modules 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 revenue.


HEDIS solution is a comprehensive end-to-end solution 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 module 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.

Pay For Performance

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 module 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

Care Gaps

MedHOK’s Care Gaps 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 population 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.The Care Gaps module uses MedHOK’s embedded NCQA® HEDIS™ certified engine as well as other performance measures, including ACG 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.

How Can MedHOK Help You?

Would you like to know more about how MedHOK’s enterprise software platform can help you stay compliant and manage Risk, Care, and Quality across your organization? Complete the form and a member of our team will reach out to you shortly.

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