Closing Care Gaps to Improve HEDIS
Performance and Compliance
To strengthen HEDIS performance and compliance visibility, a U.S. healthcare payer adopted AI-enabled automation to close care gaps faster.
A leading U.S. healthcare payer serving 2.8 million Medicaid members needed to improve HEDIS scores and regulatory compliance. Manual reviews, disconnected data, and limited provider engagement were slowing performance and increasing operational strain.
Manual Record Reviews
Medical record reviews consumed significant time, delaying care gap identification
Fragmented Data Landscape
Data silos limited visibility into member health and compliance performance
Limited Provider Engagement
Providers lacked automated reminders, increasing administrative burden and delays
Delayed Reporting CyclesSlow data collection impacted compliance timelines and performance tracking
To improve compliance and care quality, the payer shifted to an AI-enabled model that prioritized high-impact interventions, automated record handling, and enabled real-time visibility across performance metrics.
AI-driven Analytics Triage
Prioritized high-value cases in real time to accelerate care gap closure
Automated Medical Record Reviews
Reduced manual effort through AI-enabled data collection and near real-time updates
Targeted Provider OutreachEnabled automated reminders to improve HEDIS measure submissions
Improved HEDIS scores year-over-year
Driven by better care coordination and resource utilization
Higher preventive screening rates
Enabled through targeted member engagement and incentives
Reduced manual workload
Freed up staff to focus on care delivery
