Outcome-based model eliminates financial risk and helps plans close more HEDIS gaps using existing medical records

Advantmed, a leading provider of risk adjustment and Quality improvement solutions, today announced the launch of its Pay for Quality: HEDIS Abstraction offering—an industry-first, outcome-based solution that enables health plans and risk-bearing entities (RBEs) to close Healthcare Effectiveness Data and Information Set (HEDIS®) gaps by paying only for successful, compliant findings.

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Outcome-based model eliminates financial risk and helps plans close more HEDIS gaps using existing medical records

Health plans and RBEs possess vast volumes of medical records yet are often unable to fully leverage them to improve Quality performance. Reviewing every chart is cost-prohibitive, even with AI-enabled solutions, which are typically priced per chart reviewed, rather than outcomes achieved, and still require 100% clinical abstractor validation. As a result, organizations face significant financial risk without guaranteed Quality improvement, making it difficult to secure budget and demonstrate measurable return on investment. Additionally, year-round HEDIS abstraction has historically been narrow and targeted, limiting the ability to identify broader gap closure opportunities. These challenges come at a critical time, as the National Committee for Quality Assurance (NCQA) continues its transition away from hybrid measures by 2029, increasing the importance of accurate, compliant data capture.

Advantmed’s Pay for Quality model directly addresses these challenges by aligning cost with outcomes. Clients only pay when Advantmed identifies a compliant numerator or exclusion, eliminating upfront financial risk while ensuring measurable Quality impact.

“Our Pay for Quality offering fundamentally changes how health plans approach HEDIS abstraction,” said Matt Lambert, CMO & Head of Product Strategy, at Advantmed. “Instead of paying by the chart, plans can now pay only when meaningful, compliant gap closure is achieved. This ensures a clear, outcome-driven return on investment while strengthening overall Quality performance.”

Powered by Advantmed’s proprietary AI-assisted workflow and validated through a rigorous, multi-stage clinical review process, the solution delivers accurate, compliant abstraction aligned with CMS and NCQA specifications. The offering supports a wide range of Medicare Advantage Star measures and provides flexible options, allowing clients to leverage existing medical records, submit targeted gap closure lists, or utilize Advantmed’s retrieval services.

Advantmed also enhances transparency and operational efficiency by providing hyperlinked medical records with highlighted clinical values, flexible data exports, and integrated collaboration tools. Rapid turnaround for Primary Source Verification (PSV) ensures health plans can meet submission timelines and maximize Quality performance.

By shifting the abstraction model from volume-based pricing to outcome-based pricing, Advantmed enables health plans to reduce administrative burden, eliminate financial uncertainty, and accelerate measurable improvements in HEDIS performance and Star Ratings.

For more information about Advantmed’s Pay for Quality: HEDIS Abstraction offering, contact info@advantmed.com.

About Advantmed

Founded in 2005, Advantmed is an industry-leading provider of medical record retrieval, medical record review, and health assessment solutions for health plans and providers. Through a tailored, cost-effective suite of services addressing risk adjustment and quality needs, Advantmed helps organizations improve healthcare outcomes and overall performance.

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By shifting the abstraction model from volume-based to outcome-based pricing, Advantmed enables health plans to reduce administrative burden, eliminate financial uncertainty, and accelerate measurable improvements in HEDIS performance and Star Ratings.