Clinical Quality

HEDIS and Star Ratings are key metrics for measuring payer quality for government programs and value-based care arrangements that require payer-provider collaboration. With the insights delivered by clinical lab-testing results, Prognos equips payers to target and locate hard-to-find member lab test dates and values, to automatically close HEDIS and Star Ratings care gaps.

Since clinical lab data serves as supplemental data for HEDIS and Star Rating measurement, with Prognos, payers can accelerate their rating improvement. Quickly gain early notice of outcomes-based trends to inform timely, actionable corrective actions that need to be taken prior to submission requirements and better prioritize chart reviews.

Positively Impact HEDIS Scores Earlier 

Proactive HEDIS measurement and management is key to ensuring payers reach quality standards. Prognos leverages clinical lab-testing insights and uses proven algorithms to identify members with specific HEDIS care gaps, identifying corresponding clinical lab-testing values that close the gap. The lab-testing results serve as evidence to close measurement gaps, and can be submitted to a certified HEDIS quality measurement and reporting platform or to NCQA as supplemental data in the new Interactive Data Submission System (IDSS) format requirements.

Clinical lab-testing values are available promptly, and payers can use the data to proactively manage specific members and encourage high-quality care. As a result, payers are equipped with insight to positively impact HEDIS scores earlier. For example, a payer with Medicare Advantage can use clinical lab data to evaluate HEDIS measure performance for Comprehensive Diabetes Care – HbA1c control.

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Prognos identifies 10-15% more conditions than claims, resulting in 6-10% more care gap closure rate during a HEDIS season

Increase Star Ratings (Quality Rating System)

Medicare Advantage plans are already required to report their Star Ratings. Starting with the 2020 plan year health plans on Affordable Care Act (ACA) exchanges will be required to display quality-rating information in all states on their 2019 performance. This expansion of Star Ratings means that more effort is needed by payer quality teams to measure, impact, and report Star Ratings. Clinical lab-based insights are valuable for both government programs to improve HEDIS numerators and close gaps.

Realize Rapid Benefits to:

  • Ensure accurate member health status
  • Identify which members need targeted outreach for more timely interventions 
  • Create a format that can be submitted as supplemental data

For the ACA plans, our solutions can be leveraged to improve initiatives that cover annual monitoring, screenings, diabetes care, prenatal and postpartum care. Medicare Advantage plans use clinical lab-testing data to inform diabetes care and screenings. This level of insight is very valuable for achieving the high-quality clinical outcomes that are needed to achieve a five-star plan.

Improve Medicaid Quality Performance

Payers with managed Medicaid programs are often required to measure and report performance against a set of state-specific standards. With extensive reach nationwide, Prognos collects and consolidates cross-payer, historical, and current clinical lab data to drive quality performance for managed Medicaid plans. Clinical lab-testing results gives insight into initiatives for testing, screening, and prenatal and postpartum care. The data gives valuable and actionable insight on new and existing members.

With member-level and provider-level insight, payers are equipped to perform targeted outreach, which can help to improve quality measures as well as submit supplemental data to state reporting systems with the goal of better supporting managed Medicaid members and their providers.


HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)