Client Results: Restructuring Stars Program Boosts Revenues by $30M

Hands-on, data-driven custom restructuring of a Stars Program increased the rating from 3.0 to 4.0 and earned the MCO a Quality Bonus Payment.

Challenge

The client’s Medicare Advantage plan dropped from a Star rating of 4.0 to 3.0, losing their ability to receive a Quality Bonus Payment. The substantial loss in revenue was a result of no formal accountability, decentralized reporting capabilities and little awareness of Stars across the organization. They needed a dedicated budget and team specific to Medicare Stars and a holistic approach for a centralized Stars governance model.

Solution

The ProspHire team conducted a comprehensive Stars program assessment and corresponding operational readiness review. The assessment enabled the team to generate a SWOT analysis and provided the opportunity to deliver a strategic roadmap for sustainable Stars success. Additionally, ProspHire leveraged their analytics partner, Hyperlift, to couple data-backed decision making with the ability to forecast measure level scores and quickly adjust the plan as needed. Upon completion of the assessment, the ProspHire team served as interim Stars team members including the interim Director of Stars role to stabilize the program and provide foundational structure. The ProspHire team implemented governance and oversight capabilities aimed at improving Stars performance for short and long-term initiatives. During the stabilization and foundational phases, the ProspHire team recruited and successfully onboarded FTEs to support the clients Stars team. This transition employed strong change management controls and hold-over advisory services to ensure client success.

Result

The ProspHire team was able to successfully enable the client to achieve 4.0 Stars performance and recapture the Quality Bonus Payment revenue, which increased MA revenues by nearly $30m dollars. Our team of experts were able to support the client along their way to function in a strong matrixed relationship with the larger business, serving as program managers and subject matter experts for Medicare Stars. The team oversees several ongoing Stars initiatives and proactively mitigates up and downstream Stars risks.

Deliverables

Measure Assessment
Stars Program Governance and Accountability Structure
Stars Playbook
Measure-Level Intervention Charters
Intervention Reporting Dashboards

Client Overview

The client is a Managed Care Organization that offers coverage to members in the Mid-Atlantic and Southeastern region. They provide coverage to roughly 600,000 members and offer a suite of diversified products, including Medicare Advantage, Medicaid and Commercial insurance.