Health Plans
Plan performance at scale requires expertise your team may not have time to build internally.
Medicare Advantage plans and managed care organizations manage risk, quality, and utilization across hundreds of thousands of members simultaneously. We help you build the programs and operational infrastructure that make that performance sustainable.
The Landscape
Three dimensions of plan performance, all moving at once.
Star ratings affect premium revenue. Risk adjustment affects baseline payment. UM programs affect medical expense ratio. None of these operates in isolation, and most plans struggle to resource all three at the level of rigor regulators and financial performance require.
Each Star tier affects plan revenue and competitive positioning. We build the gap closure programs that move the measures that matter most.
See how we approach this →RAF accuracy determines whether CMS payment reflects your population's actual clinical complexity. Prospective programs, retrospective review, and RADV defense.
See how we approach this →UM programs that are clinically sound, operationally efficient, and aligned with current CMS prior authorization requirements.
See how we approach this →How We Engage
Flexible engagement models built around your capacity.
Some clients bring us in for a defined project, a RADV audit, a Star rating strategy refresh, a UM program redesign. Others embed us as an extension of their team for ongoing program management.
Regulatory Priorities
Key areas driving plan program requirements in the current regulatory environment:
- CMS Prior Authorization Interoperability Rule (CMS-0057-F)
- MA Star Rating methodology updates
- Risk Adjustment Data Validation (RADV) audit expansion
- NCQA HEDIS & UM accreditation standards
- State-specific network adequacy & UM requirements
Let's talk about your plan's performance priorities.
We'll identify the highest-leverage opportunities across risk, quality, and utilization.