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How Humana Replaced Manual Workflows with Digital Reporting Tools to Support HEDIS® and Risk Adjustment

Humana partnered with Availity to digitize risk and quality reporting, enabling providers to address care gaps and validate risk within their existing workflows.

About Humana

Humana Inc., headquartered in Louisville, Kentucky, is a for-profit health insurance company serving over 17 million members, including 8.7 million Medicare members. It ranks as the fourth largest health insurance provider in the U.S.

Challenge

Humana and a leading regional healthcare organization faced a mutual challenge: outdated, manual workflows known to slow progress on closing care gaps and improving quality performance. Some operational burdens such as faxing and mailing the care gap forms to providers created delays, increased administrative costs, and resulted in inconsistent documentation. These inefficient processes make it difficult to share timely, accurate information needed for HEDIS and risk adjustment efforts, ultimately affecting the quality of care.

Furthermore, Humana struggled to engage smaller in-network providers who found the documentation process tedious and overwhelming. Providers received mailers with 20 to 30 pages of forms, which had to be completed manually in order to identify and report care gaps. Without access to real-time, many providers were disengaged—limiting visibility into patient needs and slowing the closure of care gaps.

Humana recognized the need for a digital solution that would streamline workflows, lessen the administrative load, and actively engage providers in improving quality care.

Solution

To overcome the challenges of manual processes and low provider engagement, Humana partnered with Availity to launch a Clinical Quality Validation (CQV) program that digitized care gap reporting across a large network of providers. The CQV tool created a single, multi-payer digital workflow, enabling providers to receive real-time notifications of care gaps and electronically submit updated documentation. This eliminated the cumbersome, and often overwhelming, need to submit documentation via paper forms and faxing, streamlining the process and improving clinical data interoperability.

The pilot program included 7,000 providers who had previously been disengaged due to manual workflows. Availity continuously incorporated additional features, based upon payer feedback, including alert notifications, which enhances usability and adoption. Following the pilot’s success, the CQV tool was expanded across Humana’s network as a core solution for efficiently closing care gaps.

Building on this momentum, Humana introduced the Risk Condition Validation (RCV) tool to complement CQV. This integrated solution allows providers to simultaneously address care gaps and risk documentation within a single streamlined workflow; simplifying provider tasks and improving data quality. To drive adoption, Humana collaborated with Availity on targeted communications, including email campaigns and in-platform banners, alerting providers to outstanding care gaps.

Results

Average of 2 care gaps closed per each electronically submitted form during the pilot.

34,000 care gap measures submitted via the CQV tool by October 2024.

70% of providers engaged with CQV and RCV tools, up from 25%.

Provider no-match rates dropped from 15% to under 1%, reducing time spent searching for patient information.

Ready to take the next step toward efficient, accurate care gap reporting?

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