Win on Quality. Protect Your Stars. Excel in Risk Adjustment.
Ensure Data Solutions delivers the complete VBC OS™ for health plans — predictive Stars optimization, quality management, risk adjustment with AI Documentation Auditor, care management, and financial analytics. Every module CTF™ — Customizable to Fit your programs, contracts, and populations.
The Health Plan Pain Points Ensure Eliminates
Stars Rating Volatility
CMS rule changes, measure cut points, and care gap backlogs create unpredictable Stars trajectories. Without real-time scenario modeling, you are managing your most valuable bonus revenue on guesswork and delayed data.
Incomplete RAF Capture
Undercoded chronic conditions and missed HCC suspects leave millions in risk adjustment revenue on the table — and create inaccurate risk scores that distort financial planning and CMS benchmark calculations.
Fragmented Quality Data
Quality data scattered across EMRs, claims, labs, and pharmacy makes real-time gap tracking nearly impossible — leaving quality staff chasing paper instead of closing gaps before data submission deadlines.
High Medical Cost Ratios
Without real-time utilization analytics, service fund management, and PMPM trend tracking, it is nearly impossible to proactively manage total cost of care under risk contracts before month-end surprises materialize.
Disconnected Member Engagement
Reaching at-risk members before hospitalization, readmission, or care gap closure deadlines requires coordinated multi-channel outreach and MOC care plan compliance tracking most plans lack the infrastructure to execute.
RADV Audit Exposure
CMS RADV audits require airtight HCC documentation, one-best-medical-record evidence packages, and reconciled submission files. Manual processes create multi-million-dollar recoupment exposure and audit scrambles.
Purpose-Built VBC OS™ Modules for Health Plan Priorities
Every VBC OS™ module is CTF™ — Customizable to Fit your programs, contracts, and workflows. Deploy the full VBC OS™ or embed individual modules via API.
Stars Optimization & Scenario Planning
Real-time CMS Stars performance dashboards, measure weighting models, cut-point analysis, and "what-if" scenario planning. Identify the highest-ROI Stars interventions before the quality data submission window closes.
- Full Stars measure dashboard: current vs. prior period performance comparisons
- Scenario modeling: project impact of improving key measures by 5%, 10%, 15%
- CMS measure weighting and cut-point analysis built in to every Stars dashboard
- Member experience simulation to forecast member satisfaction score impact
Quality Management
Quality measures calculations via API or on-platform with real-time care gap dashboards by member, provider, and measure. Automated omnichannel outreach to close gaps — integrated with your EMR and member engagement channels.
- Open/closed gap status by member, provider, and quality measure in real time
- One-click care gap lists for care coordinator workflow assignment and tracking
- NCQA-certified calculations — the gold standard for MA, Medicaid, and ACA plans
- Health Risk Assessment and HRSN/SDOH screening integration
End-to-End Risk Adjustment + AI Documentation Auditor
Prospective HCC suspects, retrospective gap analysis, CMS submission tracking, AI Documentation Auditor for automated chart review at scale, RADV defense packages, and CMS Audit Universe file generation — across CMS-HCC V28, ACA, and Medicaid models.
- Prospective HCC suspect identification from EMR and claims data
- AI Documentation Auditor: NLP chart review surfaces undercoded HCCs in minutes
- RADV-ready one-best-medical-record evidence packages per HCC code
- CMS Audit Universe file generation — RADV audit readiness built in
Service Fund & Utilization Analytics
Real-time service fund performance, PMPM cost trending, admits/1,000 benchmarks, pharmacy cost analysis, and provider stop-loss monitoring — exportable in Excel, PDF, CSV, and HTML for actuarial and finance team workflows.
- Admits/1,000, ER visits/1,000, and readmission rate dashboards
- HMO service fund performance by plan, period, and population segment
- Provider stop-loss analysis and projected claims cost exposure
- Multi-format data export: Excel, PDF, CSV, HTML for payer reporting requirements
Population Health, IDCT & Care Management
Hospitalization-risk stratification, validated across a seven-model LLM ensemble, interdisciplinary care team coordination, specialist engagement, ADT alerts, Remote Patient Monitoring, and MOC care plan compliance facilitation — connecting every care team member to every at-risk member in real time.
- Weekly LLM-validated risk scores: High/Moderate/Low/Rising Risk for every attributed member
- Real-time ADT alerts for every attributed member admission or ER visit
- IDCT coordination: PCP, care manager, specialist, BH specialist, pharmacist, CHW
- MOC care plan delivery, engagement monitoring, and compliance reporting
High-Performance Network & Referral Intelligence
Performance-based specialist identification, premium network design, referral optimization engine, cost-share steering, and predictive Referral Management Intelligence — reducing leakage, cutting specialty variation, and aligning your network with VBC contract performance goals.
- Specialist ranking by risk-adjusted outcomes, cost efficiency, and episode performance
- Premium and narrow network configuration by specialty and geography (CTF™)
- point-of-referral decision support — guideline-concordant, under 10 seconds
- Cost-share and copay steering toward high-performing network providers
How Health Plans Use the VBC OS™
Stars Gap Closure Before Lock-In
A Medicare Advantage plan uses EnsureSTARS™ to identify 8 measures where a 5% improvement moves them from 3.5 to 4.0 Stars — then deploys EnsureCM™ to execute targeted outreach before the quality submission deadline.
RADV Audit Preparation
Plan uses EnsureRAF™'s AI Documentation Auditor and CMS Audit Universe generator to reconcile all HCC submissions against CMS acceptances 6 months before RADV windows close — eliminating last-minute documentation scrambles.
Service Fund Performance Management
Finance team tracks PMPM cost trends, service fund balance, and stop-loss thresholds in real time via EnsureFIN™ — enabling proactive utilization management before cost overruns materialize at month-end.
Premium Network Launch for MA Product
Plan uses EnsureXCEL™ to identify top-performing specialists, configures a premium network with reduced member cost-share, and steers referrals toward it — reducing specialty variation while improving outcomes.
High-Risk Member Identification & Outreach
EnsureCM™ stratifies the entire membership population weekly. Care managers receive prioritized work lists with actionable interventions — focusing effort where it prevents the most hospitalizations and cost.
Delegated Provider Quality Monitoring
Medical director team monitors quality compliance across all delegated provider groups in real time via EnsureQUAL™ — identifying underperforming practices 6+ months before traditional HEDIS cycles reveal gaps.
Ready to Protect Your Stars and Capture Every Risk Dollar?
Join Medicare Advantage and Medicaid plans using the VBC OS™ to achieve top-tier Star Ratings, close documentation gaps, and manage total cost of care. Request your tailored health plan demo today.