A health plan’s reported HEDIS score can sit 18 points below its real performance, even when members are getting the care they need. That was one of the takeaways from the recent webinar, “Connect Once, Improve Every HEDIS Quality Measure: The Benefits of Continuous Clinical Data Exchange”, we hosted with NCQA. During the session, we looked at why that challenge exists, what it costs payers, and why the shift to digital HEDIS makes solving it urgent.
The session brought together Bobby Minatra, Account Executive at NCQA, along with Nolan Kelly, Chief Commercial Officer, Alisa Haman, Director of Product Management, and Ryan Ingram, Director of Sales Engineering, all from 1upHealth.
This blog covers three key takeaways from the webinar, along with the Q&A that took place throughout the session.
1. Many of your “care gaps” are really data gaps.
Claims and clinical data aren’t two copies of the same record. Claims show what was billed. Clinical data – labs, screenings, care plans, and visit notes – is the proof that care was delivered, and it sits inside provider EHRs where payers can’t see it.
Nolan made the point with a colorectal cancer screening example. A fictional health plan has 22,400 members in the measure denominator and a reported screening rate of about 55%. But that denominator is really four populations, each needing a different focus:
| Population | # of Members | What’s Really Going On |
| Screened, and the claim proves it | 12,300 | Your reported rate today |
| Screened, but proof never reached the plan | 4,000 | A data gap: a FIT kit, or a colonoscopy before the member enrolled |
| Should be excluded, but no record | 100 | Hospice, prior colectomy, or cancer history the plan can’t document |
| True care gaps | 6,000 | Where outreach dollars should go |
When a plan closes the data gap and captures the exclusions, its rate moves from 55% to 73% without a single additional screening.
That matters because Medicare Advantage (MA) Star Ratings round to the nearest half star. A plan scoring 3.73 is a 3.5-star plan, while a plan scoring 3.75 rounds up to 4 stars. For a midsize MA plan, the jump from 3.5 to 4 stars is worth an estimated $40 million to $60 million a year in quality bonus payments.
The takeaway for payers: a low quality score isn’t always a care problem. Often, it’s a data problem. The plans that win aren’t always delivering more care. They’re the ones that can prove the care already happened.
2. The digital HEDIS clock is already running, so start with the data.
Bobby laid out NCQA’s timeline: organizations are targeted to be fully digital by measurement year 2029, with a shift to digital-only by measurement year 2030. He said NCQA is on track.
NCQA has seen plans moving from traditional to digital HEDIS take 18 to 24 months to reach production. With roughly three years left before 2030, that leaves little room to wait.
The broader policy picture points the same way. CMS is driving digital-first quality measurement across payer and provider programs. That requires data that is interoperable, standards-based, and trusted, which is why FHIR is central. And 17 of the 24 Universal Foundation measures are HEDIS measures, making HEDIS critical to payer-provider alignment on quality.
Nolan connected this to the interoperability work plans are already doing. CMS-9115 and CMS-0057 can look like isolated compliance burdens. Viewed together, they’re the foundation for digital quality measurement.
Bobby’s call to action was simple: data preparation, from mapping to clinical data access, is the heaviest lift of the transition, and plans can start on it today. “It’s not an if; it’s a when,” he said.
3. Connect once, and the data keeps flowing for payers and providers.
The manual workaround to close a data gap is expensive. A 1upHealth customer with about 100,000 members describes pulling as many as 20,000 charts a season through faxes, portals, and chart chases, at a cost that can exceed $750,000. And it still misses significant amounts of data.
Moreover, the old model asks providers for the same data again every season. The model Alisa and Ryan described in the webinar replaces manual, repetitive processes with a single connection to the provider’s EHR FHIR API, after which clinical data flows continuously in the background.
That changes the math. Plans capture the screenings, labs, and exclusion evidence that claims alone miss, so they get credit for care members already received. Chart chase shrinks, and every new connection builds the standards-based data foundation digital HEDIS requires.
1up Clinical Connect acquires clinical data directly from certified EHRs and combines it with claims data, including historical claims from Payer-to-Payer Data Exchange, into one longitudinal member record. It is EHR-agnostic, connected today to Epic and athenahealth, with more integrations coming soon.
The provider lift is deliberately light:
- The provider installs the 1upHealth Connector app from their EHR’s marketplace.
- Payer, provider, and 1upHealth review a member roster, matched by FHIR ID or by exact demographic match.
- A short testing phase confirms data is flowing.
- Data acquisition then recurs on its own, with low to no ongoing work from either side.
Providers keep visibility and control. They see ingestion reports showing what data left their system, and plans can limit the scope of each pull, for example, to the last six or twelve months.
Ryan’s demo showed what changes on the payer side. One member, Alice, had robust claims but almost no clinical data. Another, Andre, was treated by a connected provider, and his record was filled in with labs, allergies, and diagnostic reports, including a high blood pressure reading that warranted outreach. Population Insights, 1up’s query tool, then lets the team ask plain-language questions across the whole membership, such as who has an open colorectal screening gap, and export the list to care teams or vendors.
The timing is right for this conversation with providers. Every plan is standing up a Provider Access API to share claims and clinical data with network providers. 1up Clinical Connect lets data flow in both directions, turning a one-way compliance requirement into a true two-way data exchange.
Your 1up Clinical Connect Questions, Answered
Attendees sent in strong questions throughout the session. Here are the answers our speakers gave, lightly edited for clarity.
Getting Providers Connected
Q: Who from the provider organization needs to be involved?
A: Fewer people than you’d expect, though it varies. Typically that includes the provider’s contracts contact (most provider agreements already include data-sharing provisions), an EHR administrator or IT lead, and whoever handles chart and file requests today. The minimum is one person to enable the app. In one recent implementation, a provider’s data quality lead joined voluntarily to find inconsistencies between payer and provider records and was glad they did.
Q: Will providers face charges from their EHR vendors to connect their API to our plan?
A: In most cases, no. 1up Clinical Connect pulls from the certified FHIR APIs made available under the 21st Century Cures Act, and fees haven’t been a barrier so far. If a provider has questions, our team is happy to talk through their specific situation.
Q: What if a provider’s EHR doesn’t support USCDI v3.1?
A: Certified EHRs are required to support it as of January 1, 2026, and we haven’t encountered one that doesn’t. If an EHR is nonconformant, or the provider runs a homegrown system, the payer, the provider, and 1upHealth can work out which data elements are available.
The Data You Get
Q: How far back can you pull data?
A: That’s up to you. You can request a provider’s entire clinical history with a member, or limit the pull to a window such as the last six or twelve months. The scope is set in the roster itself, so you get only the minimum data you need.
Q: Does “claims data” include only the member’s current plan, or historical claims from previous payers too?
A: Both. If your plan has activated its 1up Payer-to-Payer Data Exchange API workflow and collects member consent at enrollment, historical claims from prior payers come into the same longitudinal record in 1upHealth, alongside your own claims and any clinical data you acquire.
Scale and Validation
Q: Does Population Insights scale to a plan with a million members?
A: 1upHealth is built to support payers with millions of members, so performance at that scale is a core requirement. Query engines autoscale, and for very large plans the team configures the environment up front so users don’t hit limits in practice. The goal is that anyone can query the population without technical skills or long waits.
Q: Is 1upHealth an NCQA DAV-certified vendor, or seeking DAV certification?
A: No, 1upHealth is not currently pursuing Data Aggregator Validation certification, however, we are participating in NCQA’s beta Data Quality Solutions program, and provided key feedback to their initial metrics review. NCQA is working to modernize their program and shift data quality validation closer to the source, so it can be continuously monitored at scale and reduce primary source verification burden. 1upHealth works closely with NCQA and may assess pursuing this program once it goes live in early 2027.
Get Started With Clinical Data Acquisition
The move to digital quality measurement is happening, and the plans that prove the care they already deliver will capture the Star Ratings, revenue gains, and patient care improvements that come with it. The first step is getting continuous access to clinical data.
Watch the full webinar on demand, or talk to our team about how 1up Clinical Connect can close your data gaps.
