CARE GAP CLOSURE · HEDIS® · STAR RATINGS
HEDISAi
An autonomous AI platform that continuously identifies care gaps, automates quality measure tracking, and orchestrates member and provider actions to improve HEDIS performance, enhance compliance, and drive better patient outcomes at scale.
Trusted · Transparent · Accountable
Quality is still reactive and it's costing plans Stars
Health plans aim for higher quality scores, but providers and care teams fight fragmented systems, delayed
data, and lost opportunities to act on gaps during the encounter. Within HEDIS, roughly 60% of measures
require successful member contact a phone and chart problem at a scale humans cannot economically
run. The result is a year end abstraction crunch instead of continuous closure
WHERE TODAY'S MODEL BREAKS DOWN
Fragmented, delayed data
20+ disparate sources, manual CCD loads, no
standardized layouts, and unresolved member identity
stall gap visibility
Manual abstraction burden
Chart review and primary-source verification consume
clinical time and don’t scale to MA member volumes
Retrospective reporting
Gaps surface at year-end after the window to act has
closed turning quality into cleanup rather than care.
Lost Stars & revenue
Missed screenings lower HEDIS scores and Star Ratings,
forfeiting Quality Bonus Payments and reimbursement.
THE SHIFT: RETROSPECTIVE REPORTING → REAL-TIME, AI-DRIVEN CLOSURE
Year-end HEDIS scramble
AGENTIC
ENGINE
Always-on care gap closure
A swarm of specialized agents, one continuous loop
HEDISAi is a stateful, event-driven agent platform — not a batch pipeline. Each patient event flows through
a graph of specialized agents that reason over a longitudinal Patient 360 record, with a hard guardrail: no
gap closes without validated clinical evidence
AGENT 01
Gap Detection
Continuously scans the population to
identify missing HEDIS measures in real
time.
AGENT 02
Risk & Prioritization
Ranks members by clinical severity,
time-sensitivity, and cost-avoidance
potential.
AGENT 03
Care Pathway Planning
Selects the optimal intervention to
minimize friction and maximize
completion.
AGENT 04
Outreach Orchestration
Executes HIPAA-safe, multi-channel
engagement (SMS / IVR / email / app /
call).
AGENT 05
Provider Engagement
Surfaces gap summaries, order
suggestions, and ICD/CPT coding
guidance at the point of care.
AGENT 06
Evidence Validation
Confirms closure from authoritative
lab/EHR/claims sources prevents
false closure
END-TO-END CLOSURE WORKFLOW
Ingest & normalize
Streaming FHIR data unified into a Patient 360 longitudinal record.
Detect gaps live
Measure engine + AI score every member for open and emerging gaps.
Prioritize outreach
Agents rank by risk and value to build the daily action list.
Engage & assist
Personalized member outreach plus provider documentation support.
Validate closure
Evidence agent confirms the care event from authoritative sources.
Learn & improve
Outcomes feed model retraining — best channels and pathways compound over time.
Measurable lift across quality, cost, and operations
50–70%
Faster care gap closure
Real-time detection replaces the
year-end crunch.
30–50%
Less manual abstraction
Automated retrieval, cleansing,
and validation
↑ Stars
Higher Star Ratings trajectory
More closed gaps lift HEDIS
composite & bonus eligibility
↓ PMPM
Lower medical cost
Preventive care and earlier
intervention reduce downstream
spend.
HIGH-LEVERAGE MEASURES HEDISAI TARGETS
| MEASURE | INTERVENTION | AI LEVERAGE |
|---|---|---|
| BCS — Breast Cancer Screening | Schedule mammogram | Very High |
| COL — Colorectal Screening | FIT kit ship + confirm | Very High |
| CBP — Controlling Blood Pressure | Home BP reading + PCP visit | High |
| SPD — Diabetes / A1c Control | Lab order + reminder | High |
| COA — Care for Older Adults | Functional assessment call | High |
FAQ
FDA SaMD risk tiers, EU AI Act Annex III, and clinical domain classification — out of the box on day one. Horizontal tools require weeks of custom configuration.
Auto-mapping to FDA, ONC, CMS, CHAI, NIST, and ISO maintained as regulations evolve. No manual update cycle, no compliance drift.
Calibrated to known clinical disparities: pulse oximetry bias, pain assessment inequity, maternal mortality gaps. No generic fairness proxies.
FDA post-market reports, Joint Commission evidence packages, and ISO 42001 audit-ready documentation generated automatically from governance activities.
Tracks PHI provenance through AI pipelines using healthcare interoperability standards — the only governance platform built natively on healthcare data infrastructure.