Author: LBodnarchuk

The first $10 billion installment of the Rural Health Transformation (RHT) Program has been distributed, with allocations ranging from $147 million in New Jersey to $281 million in Texas. Over the next five years, the full $50 billion federal investment will flow through state-led transformation strategies.

Created alongside nearly $1 trillion in projected Medicaid spending reductions over the next decade, the RHT fund was designed to soften anticipated rural fallout while giving states flexibility to innovate. Federal leaders have emphasized that states have “space to be creative” in designing their transformation approaches. As CMS Administrator Mehmet Oz noted following the announcement, “Some states will fail and we will learn from that.”

That framing matters. It signals three things:

1. There will not be a uniform national model.
2. Outcomes will vary significantly.
3. Execution capability will determine durability.

Without integration across these domains, funding risks fragmentation across well-intentioned but disconnected initiatives. RHT does not fund isolated projects. It implicitly demands operating model redesign.

Flexibility Increases Variance

States have latitude in how they deploy funds across approved categories, including prevention, workforce investments, technology modernization and care model innovation.

Flexibility encourages innovation. It also increases variance.

Some states will build coordinated, multi-year transformation roadmaps aligned to performance metrics and CMS reporting expectations. Others may distribute funds broadly without sequencing structural change.

The difference will not be intent. It will be implementation discipline.

The Medicaid Backdrop Changes the Stakes

RHT is unfolding amid broader fiscal pressure within Medicaid. For rural communities already operating with thin margins, transformation cannot be additive spending layered onto unstable foundations.

Sustainability will require:

• Aligning payment reform with provider capacity
• Ensuring workforce investments include retention strategy
• Embedding analytics infrastructure into value-based initiatives
• Sequencing modernization efforts to avoid operational overload

Rural transformation is not theoretical. It is operational. Over the next five years, the states that treat RHT as a coordinated system redesign, rather than a funding cycle, will be positioned to create durable improvements in access, quality and financial sustainability.

How geographic data and social determinants insights can help organizations identify and address maternal health disparities.

Disparities in maternal outcomes are real and persistent. Despite improvements in clinical care, preventable gaps in outcomes continue to exist, making maternal and perinatal health one of the clearest indicators of health inequity within the U.S. healthcare system. These patterns have existed for years, yet meaningful progress has been limited. The question is no longer whether inequities exist but how organizations take responsibility to address them.

Data Driven Insights

Health plans and providers see inequities through quality performance, member experience and long-term cost trends. Addressing these disparities requires more than broad programs. It requires focused strategies grounded in data and a clear understanding of the communities where members live.

To support this work, ProspHire has enhanced a sample of our Addressing Health Disparities Dashboard to highlight Maternal and Perinatal Health Equity. The dashboard brings together maternal health outcome metrics and key social determinants of health indicators at the state and county level.

This allows organizations to examine maternal outcomes alongside the social conditions that influence them.

By viewing health outcomes and SDOH indicators together, the dashboard helps organizations identify where disparities may exist and where targeted interventions or community partnerships may have the greatest impact.

From Awareness to Accountability

Organizations must move beyond identifying disparities to implementing focused programs, aligning resources and building partnerships that address the underlying drivers of equity. The dashboard is designed to start that conversation. The opportunity lies in turning geographic insight into a focused maternal health strategy that improves outcomes and advances equity across communities.

ProspHire partners with healthcare organizations to move from insight to execution, helping teams design and implement practical, scalable solutions tailored to the communities they serve.

Ready to make a difference? Partner with ProspHire to drive meaningful data-informed change in maternal and perinatal health equity. Reach out to our team today to start transforming insights into action and create lasting impact for your community.

We’re proud to congratulate six ProspHire employees: Luke Laurin, Hootan Shahidi, Jack Warwick, Ben Tarter, Lauren Lougney and Jeremy Spelios on earning the Denticon Master Trainer Certification. This accomplishment reflects more than product expertise, it demonstrates a continued commitment to growth, learning and delivering greater value to our clients.

As the dental landscape evolves, so does the technology that powers it. By deepening their mastery of Denticon and advancing their training capabilities, our certified team members are better equipped to support DSOs and partners with informed guidance, thoughtful change enablement and scalable education strategies. Their enhanced expertise ensures our clients benefit from up-to-date insights, refined best practices and a stronger foundation for long-term success.

We celebrate their dedication to continuous improvement and their ongoing commitment to elevating the client experience. This milestone reflects our unwavering focus on strengthening our capabilities so we can better serve the organizations that trust us as their partner. Congratulations!

Click here to learn more about Dental Practice Management at ProspHire.

The Challenge: Every Interaction Shapes Trust

Member experience has become one of the most powerful drivers of Medicare Advantage Stars Performance. CMS continues to raise expectations for how members experience their health plan, placing greater emphasis on trust, access, communication and consistency across the entire journey.

CAHPS performance is no longer shaped by isolated touchpoints or seasonal outreach. It reflects how members feel about every interaction, across every channel, over time. There are no silver bullets. Sustainable CAHPS success is built through consistency, stability and brand credibility… doing the right thing, at the right time, for all members.

When experience efforts are disconnected from journey insights or only activated during survey season, plans risk missing the true drivers of member perception, loyalty and trust.

What Successful Plans Are Doing Differently

High-performing plans treat CAHPS as an always-on, insight-driven experience strategy rather than a one-time campaign. These organizations are:

• Using member journey insights to understand the triggers, transitions and barriers, such as network and benefit changes or service disruptions, where proactive outreach has the greatest impact.
• Delivering timely, personalized outreach through moment-based interventions thatfeel relevant and supportive. Real-time signals and operational data are used to trigger the right message, through the right channel, at the right time.
• Aligning the entire ecosystem around consistency, ensuring internal teams and vendor partners operate cohesively. These plans recognize that trust is cumulative. Every touchpoint, regardless of who delivers it, contributes to the survey response.

Three Priorities for Data-Driven CAHPS Improvement

Our Perspective

At ProspHire, we believe CAHPS improvement starts with trust and is sustained through disciplined, insight-driven execution. By connecting member journey data with operations and member experience strategy, plans can move beyond short-term survey tactics and build relationships that drive long-term loyalty and Stars performance.

Design Experiences That Members Remember

CAHPS results are shaped long before the survey arrives. Now is the time to rethink how journey insights, moment-based outreach and consistent experience delivery work together to build trust, elevate satisfaction and drive meaningful results.

HHS released the 2027 Payment Notice Proposed Rule on February 9, signaling meaningful shifts for Health Insurance Exchanges, Issuers, brokers and agents. This annual notice sets the stage for potential changes and additions to the standards governing marketplace operations, plan design and compliance oversight.

As anticipated, the Proposed Rule seeks to reintroduce several requirements previously included in the 2025 Marketplace Integrity and Affordability Final Rule that were subsequently stayed by the courts prior to PY2026. These provisions include the elimination of certain Special Enrollment Periods (SEP), enhanced verification requirements for SEPs, restrictions on APTC eligibility for  undocumented individuals and stringent income verification prior to receiving APTCs.

The Proposed Rule also takes several steps to increase state authority and autonomy by removing barriers to the creation of State-Based Exchanges and shifting network adequacy requirements and reviews to the states.

Lastly, the Rule looks to ease the administrative burden on Issuers by removing duplicative certification reviews, eliminating the Standard Plan Design Requirement, relaxing Essential Community Provider (ECP) contracting thresholds and discouraging additional state-mandated Essential Health Benefits (EHBs).

Why this Matters

While states and plans may experience autonomy and procedural relief, CMS has made it clear that compliance with federal regulations remains mandatory and that non-compliance will carry consequences.

What Should Plans Do Now?

• Submit comments on the Proposed Rule by March 11
• Complete a rapid compliance assessment of all impacted operational activities, assuming the rule is codified as proposed
• Collaborate with state insurance departments to understand implications for the upcoming certification cycle
• Re-design processes and procedures to align with codified requirements
• Develop a compliance roadmap, including scheduled mock audits to proactively identify and mitigate risks

Why the first MA-guidance in decades signals a new era of scrutiny and execution.

On February 3rd, the Office of the Inspector General (OIG) released a Medicare Advantage Industry Segment-Specific Compliance Program Guidance. This marks the first time since 1999 that the OIG has issued formal, MA-specific guidance outlining its compliance expectations for Medicare Advantage plans.

This guidance clarifies OIG’s priorities and reinforces a clear message: compliance must be fully embedded into day-to-day operations. The document emphasizes strong governance, efficient and documented workflows, accountability across first-tier, downstream entities and proactive risk identification and management.

The OIG identified several areas that warrant focused and sustained attention, including:

• Access to Care (Network Adequacy and Prior Authorization)
• Marketing and Enrollment
• Risk Adjustment
• Quality of Care (Stars)
• Oversight of Third Parties
• Compliance Programs Within Vertically Integrated Organizations and Other Ownership Structures
• Submission of Accurate Claims

Why this Matters: Reinforced and Sustained Scrutiny

Medicare Advantage has been under increasing scrutiny for several years and this guidance reinforces that heightened oversight is not temporary. Recent actions by Centers for Medicare & Medicare Services (CMS), including expansion of RADV audits to all MA contracts, updated compliance protocols and a growing number of lawsuits addressing fraudulent or non-compliant behavior, signal a sustained regulatory focus on program integrity.

What Should Plans Do Now

Plans should view the OIG’s MA Compliance Guidance as a roadmap for strengthening compliance and operational risk by:

• Assessing organizational strengths and gaps to identify and prioritize key compliance and operational risks
• Establishing strong governance and accountability across all internal, delegated and downstream entities
• Implementing targeted risk assessments, auditing and monitoring to proactively identify, mitigate and manage compliance risks
• Aligning compliance strategy with quality outcomes and enterprise-wide risk management through an actionable, ongoing compliance plan

For years, ACA Risk Adjustment was treated as a technical requirement—important, but largely operational and retrospective in nature. That framing no longer holds.​

​In today’s environment of margin compression, RADV pressure and performance volatility, Risk Adjustment has become one of the few controllable levers plans still have.​

When Risk Adjustment is managed as a siloed, back-office function, plans expose themselves to preventable financial risk and downstream disruption.​

​Leading organizations are reframing Risk Adjustment as an enterprise capability. They connect data, clinical documentation, analytics, finance and operations into a coordinated model—one that supports both accuracy and sustainability.​

​This Shift Changes the Conversation:​

• From retrospective reconciliation to proactive margin protection​
• From isolated technical work to cross-functional accountability​
• From “getting it done” to getting it right​

In 2026, Risk Adjustment performance is not just a technical success factor.​ It is a strategic one.

Why This Result Matters 

This wasn’t indecision. 
It was a signal. 

When inefficiencies show up equally across people, processes, systems and data, the problem isn’t isolated, it’s systemic. Inefficiency doesn’t live in one department. It travels across the organization, compounding at every handoff and workaround. 

The Cost You Don’t See on the Balance Sheet 

These issues rarely appear as line items.  They show up as:

• Time lost to rework and manual effort
• Momentum lost during team handoffs
• Delayed decisions due to disconnected systems
• Teams operating without real-time visibility

Individually manageable. Collectively expensive. 

Key Takeaway 

Inefficiency isn’t a single problem to fix.  It’s an execution chain to break. 

What High-Performing Organizations Do Differently 

The organizations making progress aren’t chasing one-off improvements. 
They’re strengthening how work moves: aligning people, processes and systems to reduce friction end-to-end. 

Execution doesn’t fail loudly. It slows quietly until the cost is impossible to ignore.  Let’s talk about where inefficiency is slowing execution in your organization. 

The Challenge: Efficiency Matters When Every Chart Counts

Hybrid HEDIS season (aka Retrospective HEDIS project) requires accuracy, speed and coordination across analytics, operations and provider networks… all under intense time pressure. Plans are expected to close gaps at scale while navigating evolving specifications and a growing dependency on chart retrieval and medical record completeness.

Too often, teams are forced into reactive workflows:

• Chasing charts without prioritization
• Manually flagging members
• Relying on inconsistent provider responses

What Successful Plans Are Doing Differently

High-performing plans are shifting away from manual, sprint-based chart hunts to data-driven hybrid strategies. They are:

• Using advanced data analytics to improve their hybrid sample and prioritize high-impact members and providers early
• Automating chart chase workflows to reduce manual effort and enhance retrieval accuracy
• Engaging providers before hybrid season to improve documentation quality and reduce chart volume, not just chase records

These plans recognize that faster chart retrieval alone isn’t optimization. True efficiency comes from reducing avoidable chart work and creating workflows that scale year over year.

They are also:

• Strengthening supplemental data capturethroughout the year
• Improving ETL processes to ensure cleaner, more reliable data
• Making insights accessible through dashboards and self-service reporting for quality, clinical and operational teams

Our Perspective

With upcoming deadlines from NCQA and CMS regarding ECDS measure changes, digital quality measurement and FHIR based APIs, hybrid season as we know it is evolving.

However, the investments plans make now to optimize today’s programs will directly enable success in what comes next. Prospective HEDIS efforts will continue. Improved SDS capture and next-generation tools, such as natural language processing and large language models, will further enhance clinical data capture. At its core, this evolution is about one thing: ensuring plans capture the most accurate, most relevant clinical data to drive better outcomes for members… today and in the future.