Intelligent Quality Management

For healthcare payers, HEDIS (Healthcare Effectiveness Data and Information Set) scores are more than compliance metrics, they are a direct driver of financial performance. With over 191 million Americans enrolled in health plans that report HEDIS results (NCQA.org), performance on these measures influences Star Ratings, Medicare Advantage revenue, contract negotiations, and member retention. Yet traditional HEDIS management remains a manual, retrospective, and high-cost burden.

CitiusTech’s PERFORM+ platform, an NCQA-certified solution for over a decade, is now integrated with the industry’s first Generative HEDIS capability. Through an intelligent automation layer across measure computation, medical record review, and reporting, PERFORM+ enables health plans to move from compliance-driven seasonality to a continuous quality-first operating model.

Quality as a Financial Asset

The financial impact of HEDIS performance has never been more pronounced than it is now. For MAPD plans (based on CMS’s 2025 MAPD data), only 40% of health plans achieved a four-star rating or higher, which is a decline from 42% in the prior year, and a steep drop from the 5-star contracts seen in previous cycles.

HEDIS performance has become a key determinant of both financial outcomes and market competitiveness, impacting:

• CMS Star Ratings and associated revenue incentives
• Value-based reimbursement and shared savings performance
• State Medicaid quality incentive programs
• Employer group contracting and retention strategies
• Member growth, satisfaction, and brand differentiation

In today's market, improving HEDIS performance is not just about meeting regulatory expectations. It is about creating a sustainable competitive advantage. With only 62% of Medicare Advantage members enrolled in high-performing plans, the performance gap between quality leaders and lagging organizations continues to widen.

Why Manual HEDIS Falls Short

Despite the high stakes, most health plans manage HEDIS through disjointed, labor-intensive processes. The traditional approach rests on three limitations:

Retrospective, Seasonal Operating Models: Conventional HEDIS workflows follow a rigid annual cycle: population identification in late Q3, extensive chart chase during Q4, reporting in Q1, and submission in Q2. This leaves quality gaps undiscovered for months, and care opportunities missed entirely. As NCQA accelerates its multiyear transition to Digital Quality Measures (dQMs), the need for year-round, near-real-time quality management has become unavoidable. 

Manual Chart Abstraction and Review: Chart abstraction remains one of the most resource-intensive elements of HEDIS operations, requiring teams of nurses and coding specialists to manually review medical records, extract data elements, and validate measure compliance. This process introduces significant latency, high labor costs, and inherent variability across abstractors.

Fragmented Data and Provider Engagement: Clinical data resides across claims, EHRs, labs, and other clinical data systems. Most health plans struggle to normalize these disparate sources into a unified view of member quality performance. Additionally, closing care gaps depends on effective provider outreach, yet plans face persistent challenges in identifying which providers to engage for which specific gaps and this can result in high-volume, low-impact campaigns.

Reimagining Quality Management with PERFORM+

CitiusTech’s PERFORM+ platform fundamentally re-engineers the HEDIS lifecycle. An NCQA-certified solution for 10+ consecutive years, PERFORM+ is built on a modern, cloud-native architecture that delivers near-real-time performance measurement, automated data ingestion, and AI-augmented workflows.

Our core platform capabilities:

• HEDIS Measure Engine (NCQA Certified): PERFORM+ embeds pre-built, configurable measure logic aligned with NCQA specifications. The engine processes administrative, hybrid, and Electronic Clinical Data System (ECDS) measures, enabling health plans to compute performance on demand rather than in batch cycles.
• Member 360 and Measure 360 Dashboards: Configurable analytical tools provide actionable visibility into member-level quality gaps and measure-level performance trends. These interfaces allow quality teams to prioritize high-impact gaps and track closure rates across provider networks.
• Integrated Medical Record Review: An end-to-end workflow for chart chase management, abstraction, and real-time compliance tracking. The system automates chart retrieval, distribution, and abstraction completion, reducing administrative overhead while maintaining audit readiness.
• Submission Management: Seamless, error-reduced submission across NCQA HEDIS, CMS, and state regulatory agencies — eliminating duplicate data entry and submission discrepancies.
• FHIR-Enabled Data Exchange: Ready-to-use accelerators for FHIR-based interoperability, enabling real-time care gap sharing with providers and integration with EHR systems. This capability supports NCQA’s digital quality measurement transition and facilitates timely gap closure at the point of care.

CitiusTech’s Client-Deployed Impact

The PERFORM+ platform has been implemented across leading health plans, including major Blue Cross Blue Shield plans, multi-state Medicaid organizations, and provider-sponsored health plans. A leading Blue Plan enhanced its HEDIS and Star Ratings, improving gap closure by 30% using PERFORM+. A California-based health plan deployed PERFORM+ to streamline HEDIS monitoring and reporting across its entire membership, enabling integrated weekly compliance reporting and NCQA submissions.

Our GenAI Advantage

In August 2024, CitiusTech launched the industry’s first Generative HEDIS solution, deeply integrated into PERFORM+. This represents a fundamental reimagining of quality management, moving from manual, rules-based processes to intelligent, conversational, and continuously learning workflows.

Key Generative Capabilities

• Conversational Rules Generation: Quality analysts can create complex measure rules, cohort definitions, attribution logic, and inclusion/exclusion criteria all while using natural language text or voice commands. The GenAI engine translates conversational inputs into executable specifications, dramatically reducing the time required to configure new measures and adjust existing ones.

• AI-Augmented Engineering: Feature and rule development time is compressed through intelligent code generation and configuration assistance. Quality and IT teams can build measure logic incrementally, with AI surfacing recommendations, identifying conflicts, and ensuring NCQA compliance throughout the development lifecycle.

• Assisted Chart Abstraction: An intelligent abstraction assistant automates data extraction from clinical records, including unstructured PDFs and transcribed notes. The assistant highlights relevant clinical evidence, suggests compliant answers, and learns from abstractor corrections to improve over time. This capability addresses the costliest bottleneck in the HEDIS workflow while maintaining audit-grade accuracy.

Near-Real-Time Quality Management

The convergence of NCQA-certified measure computation and Generative AI enables a fundamentally new operating model. Through daily processing, PERFORM+ allows health plans to run HEDIS calculations daily or weekly rather than waiting for end-of-season reporting. This enables prospective gap closure,  identifying missing care events before reporting deadlines and intervening while members are still in the measurement window. In addition, AI-driven prioritization leverages ML-based segmentation and chase intelligence to identify the providers most likely to close specific gaps for targeted member populations. Instead of blanket outreach, quality teams focus their efforts where they will produce the highest yield.

Aligning with NCQA’s Digital Future 

NCQA is systematically moving HEDIS toward digital quality measurement. Coming up in Measurement Year 2026 (MY26), NCQA added seven new measures, transitioned four measures to ECDS-only reporting, and retired two measures. The technical specifications now align with the FHIR data standard. This transition makes traditional, manual HEDIS processes increasingly untenable. PERFORM+ is architected for this digital future. With a FHIR-native data model, accelerators for interoperability, and continuous NCQA certification, the platform enables health plans to navigate this transition without operational disruption.