Case Study: DocCare, Queens NY
Overview:
DocCare operates three primary care offices in Queens, New York, serving a diverse and growing patient population. Despite delivering high-quality care, their quality scores reported to insurers were not capturing the full picture, impacting both recognition and incentive eligibility.
HEDIS Star Ratings: Supplemental Reporting & Data Strategy
Over the course of three reporting years, HCG Consulting helped DocCare improve its HEDIS Star ratings from 1 star to 5 stars. This was achieved by designing and implementing a supplemental data aggregation pipeline that extracted and matched bulk EHR data to payer requirements.
- Identified and filled gaps between EHR documentation and claims-based quality metrics
- Built automated processes for tracking and aligning patient-level data with health plan measure definitions
- Submitted supplemental data to Healthfirst, BCBS, UnitedHealthcare, MetroPlus, and Centene/Fidelis/WellCare
- Unlocked significant annual performance bonuses through improved payer scorecards
PCMH Recertification: Custom Clinical Quality Measures
As part of DocCare’s Patient-Centered Medical Home (PCMH) recertification process, HCG Consulting developed custom Clinical Quality Measure (CQM) logic tailored to national and NCQA-aligned standards. These measures filled critical gaps that the EMR vendor could not hard-code into their reporting tools.
- Designed and coded custom CQMs using Python and R based on published CMS and NCQA specs
- Validated and matched measure logic against payer documentation to ensure accuracy
- Ensured final numbers alligned with the Measure Authoring and Development Integrated Environment (MADiE) tool test data
- Enabled accurate reporting of preventive care and chronic disease management metrics required for PCMH recognition
- Provided clear documentation and exportable summary reports for submission to certifying bodies
By transforming raw EHR data into validated reports that aligned with national quality frameworks, DocCare was able to demonstrate its high standard of care, maintain key certifications, maximize value-based reimbursement, all without significantly altering clinical workflow.