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Blog
Short-form posts on regulatory changes, quality measure updates, AI in clinical workflows, and what we're shipping at Quality Health.
Latest posts
- The Transitions of Care ECDS Move Is a Dry Run for Digital HEDISNCQA announced on August 26, 2026 that the hybrid Transitions of Care measure will move to full ECDS reporting, with the new specification targeted for MY 2028 and the hybrid version retiring in MY 2029. Because TRC sits inside the CMS Medicare Star Ratings, the move is a dress rehearsal for the whole digital HEDIS transition.
- Prior Auth Pledges Are Voluntary. The CMS-0057-F Deadlines Are Not.As of January 1, 2026, impacted payers must turn around prior authorization decisions within 72 hours for expedited and 7 calendar days for standard requests, with specific reasons for denials. By January 1, 2027, the FHIR-based Prior Authorization API is mandatory. Against that clock, the industry's widely publicized voluntary prior-auth pledges look like what KFF Health News found they are: unenforced and at risk of vanishing.
- NCQA Rating Day Is Here. What the First Full Digital-Weighted Cycle Signals.NCQA publishes Health Plan Ratings to its public Report Card on September 15, 2026, the release day for commercial, Medicaid, and Medicare Advantage plans across the 2026 measurement year. The ratings now sit on a quality measurement base that is shifting decisively toward digital HEDIS, and the plans that moved early have a visibility advantage their competitors cannot manufacture quickly.
- Employer Insurance Costs Are Surging. Quality Scores Do Not Reach Them.KFF's 2025 Employer Health Benefits Survey put average family coverage at $26,993, up 6 percent in a year, and STAT's Out of Pocket, Out of Reach series documented the small-business retreat from offering coverage. Unlike Medicare Advantage, the employer market has no quality rating system that actually touches the plans employees are steered into.
- ICHRA's Missing Piece: Health Plan Quality at the Point of ChoiceCMS rated 298 Marketplace reporting units for PY2026, and more than 99% of HealthCare.gov consumers could reach a 3-star-or-better plan, yet only 65% enrolled in one. Why the Quality Rating System does not cover the off-exchange plans ICHRA employees are steered toward, and what a quality-adjusted shopping experience has to show.
- ICHRA in 2026: Employers Are Handing Plan Choice to Their EmployeesThe number of employers offering an ICHRA nearly doubled to 12,700 by January 2026, with the fastest growth above 500 employees. What the HRA Council, EBRI-Morgan Health, Mercer, and KFF data actually show about adoption, employer hesitation, insurer strategy, and the ACA risk pool.
- Rising MLRs: Why Health Plans Are Rethinking Lines of BusinessMLR has stopped being a consumer protection number. It's now the quiet signal driving carrier exits, Medicaid pullbacks, and the reshaping of health plan portfolios.
- The New AI Threat for Healthcare: Breaking Down the OpenAI and Hugging Face BreachIn July 2026 an OpenAI model under evaluation escaped its sandbox and ran a four-day, 17,600-action intrusion into Hugging Face's production infrastructure. Why the first AI-agent breach maps directly onto healthcare data pipelines, what the OCR wall of shame and IBM's $7.42M average already show, and the six controls an AI governance program needs.
- dQMs Are Coming: What the CMS Digital Quality Measurement Roadmap Means for Health PlansCMS and NCQA are aligning on a single destination: fully digital, FHIR-driven quality measurement. Why NCQA retires hybrid HEDIS in MY 2029, what the Medicaid Core Sets mandate, and what health plans have to build before the window closes.
- CMS-HCC V28: What the New Risk Adjustment Model Changes for Your RAF ScoresCMS-HCC V28 is fully live in 2026, and the combined risk model revision and FFS normalization impact runs -3.01% against a +4.33% net MA payment change. What changed under the hood, which codes got cut, why MEAT documentation is the bar RADV enforces, and why bidirectional chart review is the only defensible posture.
- Star Ratings Cut Points: Why Your Plan's Score Depends on Everyone Else'sMedicare Advantage Star Ratings cut points derive from the prior year's industry distribution, so a plan's score is graded on a curve set by every other contract. How the tournament works, how Tukey outlier deletion changes it, and how the CY 2027 Final Rule removes administrative measures and lifts HEDIS weights for 2027 and 2028.
- From 30+ Minutes to Seconds: What AI Abstraction Actually Changes About Your HEDIS SeasonWhat AI-powered chart review changes about HEDIS hybrid abstraction: the cost math, the move from data entry to validation, the bidirectional RADV angle most gap-only tools miss, and why NCQA's shift to digital measures makes this infrastructure rather than a seasonal tool.
- Clover Health v. CMS: A Comprehensive Review of the Star Ratings LawsuitA federal judge invalidated 20 Medicare Advantage Star Ratings measures on two grounds, CMS recalculated Clover to 4.5 Stars, and the ruling opened copycat suits and an appeal that could permanently reshape the program’s legal foundation.
- CMS Killed the Health Equity Index. Here's What It Would Have Done.CMS-4208-F3 reversed the 2027 Health Equity Index and kept the historical reward factor. An autopsy of the HEI that almost was: its mechanics, the $5.12 billion it would have moved, and why the pressure to track stratified performance hasn't gone anywhere.
- Prospective vs. Retrospective Risk Adjustment, and RADV Audit ExposureProspective or retrospective is a bet on defensibility, not timing. How retrospective coding runs one way, how RADV puts a price on it, and why the 2025 court ruling is a narrower reprieve than it looks.
- ACA MLR Rebates in 2026: $759M and the Cycle Behind the NumberInsurers will pay ~$759M in 2026 medical loss ratio rebates - the lowest since 2018. An interactive look at the 2012-2026 rebate cycle, the 2020 peak, and how the 80/20 rule works.