Client Challenge

  • An EXL client had a gap throughput of 6.7% for total number of gaps closed per 100 calls made. They also faced high average hold times at eight minutes for data abstraction, six minutes for fax conversion and outreach at ten minutes.

EXL Solution

  • EXL applied automation and machine learning principles to decrease the amount of time spent waiting and improve gap closure rates.


  • Boosted Star ratings due to closed gaps
  • Increased revenue through rebates
  • Gained a leadership in market position leading to higher health plan visibility

As health care leaders know, HEDIS abstraction is a highly manual and intensive process requiring significant reviewing and auditing of large volumes of medical record information. In addition, the gathered results do not readily facilitate closing gaps in care through member or provider communication. Unmanaged gaps in care result in non-compliance with NCQA standards, leading to lower Star ratings.

Current HEDIS operations tend to focus on transactions, rather than closing these gaps. This can be caused by providers not responding or sending the correct medical records, as well as a lack of follow up process. High hold times of sub processes such as data abstraction, fax conversion and outreach can also further reduce productivity.

Completing these processes manually can consume time better spent allocating, consolidating, and mapping data with the correct records. These are all logical operational areas for automation and machine learning.

Applying automation principles can reduce the laborious and timeconsuming abstraction process while improving reporting efficiencies, cost management and clinical outcomes.

Common goals for this type of project focus on enhancing CMS client satisfaction and member outcomes, such as:

  • Improving care gap closure rates to boost Star ratings
  • Providing quality care to members
  • Increase revenue through rebates
  • Attain a leading market position by using abstraction services to increase health plan visibility to potential members

Identifying What Issues to Solve

Health plans and providers often identify several issues that require technology enabled solutions:

  • Clinical quality Improvement
    • Low gap closure rates limit health status improvement
    • Potential increase in ER and hospital utilization
    • Missed opportunities in disease and case management
  • Revenue optimization
    • Reimbursement limitations, or penalties stemming from unmanaged gaps in underperforming plans
    • Poor market position and new member acquisition due to low-quality care results
    • Provider dissatisfaction relating to pay-for-performance or quality-based compensation

Health plans can greatly benefit from using HEDIS oriented solutions to address these issues. Looking to advanced analytics to help identify, document and prioritize closing gaps in care through:

  • Allowing for provider segmentation and prioritization to facilitate member engagement
  • Providing ongoing metrics-based tools to automate and improve the efficiency of gap closure and abstraction
  • Creating a hierarchy of revenue optimization opportunities by incorporating motivational indexing of members

Process and Project Design Strategies

In order for plan and provider leadership to improve HEDIS management and processes, it is important to identify, quantify and manage opportunities to achieve a strong ROI.

Using the right approach in HEDIS process improvements can result in a high performance capability. This approach is often focused on three operational areas:

  • Outreach call to providers
  • Fax Conversion
  • Data Abstraction

Plans with fewer than four Stars can target these areas to close gaps in care and achieve positive outcomes. When undertaking such a project, the health plan leadership must consider the potential cost benefit of initiating a performance improvement program, such as the impact on the overall topline through additional rebates and bonuses provided by CMS. This information can be used to coordinate the resource commitment necessary for the project.

When health care organizations consider making performance improvements, it is important to strategize as creatively as possible. Whether done alone or in conjunction with a service provider, it is important to be as innovative as possible in constructing a solution, possibly using design thinking strategies. Such an approach requires a comprehensive, committed multidisciplinary team and open communication to construct a new solution.

Written by EXL Healthcare Team


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