Case Study: Large Medicaid Planning Company achieves 29% increase in chart collection and improved HEDIS measure rates with Optum

Improving Your Health Plan’s HEDIS Performance

Large Medicaid Planning Company engaged Optum to revitalize its HEDIS program after concerns that poor performance by an external operations partner risked regulatory non‑compliance, financial penalties, loss of NCQA accreditation, and its Medicaid contract. The plan brought Optum in late in the measurement year with limited time to act, facing significant data deficiencies, outsourced control of the HEDIS vendor contract, and the sudden need to develop remote chart‑chase capabilities because of the pandemic.

Optum deployed interim HEDIS management and technical consultants to establish a new in‑sourced HEDIS program, execute new contracting, remediate data (including adding two years of service history, correcting diagnosis coding on 18% of extracted claims, improving provider data extracts, and adding other lines‑of‑business claims), and scale remote EHR chart retrieval with a multi‑phased escalation process. The effort raised chart collection rates by 29%, improved rates across all state‑designated core measures and nearly all HEDIS measures, documented best practices and new data sources for sustained improvement, and led the plan to recommend Optum for additional engagements.