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.
Operational readiness determines whether teams adopt new systems or work around them.
What Readiness Really Means
True readiness includes:
Defined roles and decision authority
Capacity for teams to absorb change
Aligned workflows across functions
Metrics that track adoption and outcomes
The Outcome
When readiness is built into execution:
Adoption accelerates
Operational disruption decreases
Performance improves faster
ProspHire Perspective
We operationalize readiness, embedding it into delivery so systems drive measurable, sustained improvement. Operational readiness determines whether new systems are embraced or quietly worked around. When roles are clear, teams are prepared and workflows are aligned, adoption accelerates and disruption is minimized. Readiness built into execution is what enables health plans to sustain results long after implementation ends.
Health plans often declare success at go-live, yet performance improvement remains elusive months later. The issue isn’t the technology. It’s the assumption that implementation equals transformation.
Why Value Breaks Down
After launch, organizations frequently encounter:
Unchanged workflows layered onto new systems
Unclear ownership between IT, vendors and operations
Limited adoption beyond basic functionality
Metrics focused on completion, not outcomes
Without execution discipline, systems become expensive infrastructure rather than performance drivers.
What Successful Plans Do Differently
High-performing organizations:
Redesign workflows alongside system changes
Establish clear operational ownership post-launch
Invest in adoption, not just training
Measure outcomes tied to business performance
ProspHire Perspective
ProspHire helps health plans move beyond go-live by leading implementations as business change initiatives, not technical events. When execution changes, outcomes follow.
Implementation success is not defined at go-live. It’s defined by what changes afterward: how work is performed, how decisions are made and how teams adopt new ways of operating. Health plans that treat implementation as a business change, not a technical milestone, are the ones that turn systems into measurable performance improvement.
Most system implementations don’t fail outright. They stall. Timelines stretch. Decisions slow. Teams burn out managing change alongside daily operations.
Where Execution Breaks Down
Common risk points include:
Diffuse accountability across teams
Competing priorities and limited capacity
Vendor-led timelines disconnected from operations
Lack of adoption ownership after launch
Why This Matters
When execution falters:
ROI is delayed or lost
Teams revert to workarounds
Leadership confidence erodes
ProspHire Perspective
ProspHire mitigates execution risk by providing:
Clear ownership and governance
Disciplined delivery management
Alignment across IT, operations and leadership
Execution isn’t a phase; it’s the work. When system implementations fall short, the root cause is rarely technology; it’s execution under pressure. Clear ownership, disciplined delivery and operational alignment are what prevent delays, burnout and stalled adoption. Addressing execution risk early is what separates stable implementations from ones that struggle to deliver value.
The Challenge: You Can’t Improve What You Don’t Understand
In today’s Stars environment, health plans are expected to deliver stronger performance while managing varying contract maturity levels, operational capabilities, geographic variability and diverse member populations. At the same time, regulators continue to refine the program, most recently theproposed CY 2027 rule, adding complexity and volatility to an already high-stakes system.
As pressure mounts, plans must do more than improve outcomes. They must understand whether their contracts are positioned to perform, sustain and scale success.
Without a clear baseline, benchmarking or contract readiness evaluation, plans risk investing in the wrong strategies, duplicating effort or missing meaningful opportunities for improvement.
What High-Performing Plans Are Doing Differently
Leading organizations are pausing before they push forward. Rather than spreading resources evenly across contracts or chasing isolated measure improvements, they begin by gaining a clear picture of where they stand.
This disciplined approach enables targeted improvement, reduces waste and focuses effort where it will generate the greatest return.
Three Priorities for Contract Benchmarking and Readiness
Contract-Level Benchmarking: Measure competitive standing by contract to identify improvement opportunities, risk exposure and of performance leverage.
Operational Readiness Assessment: Evaluate the core health plan capabilities that drive Stars performance, including analytics, governance, provider engagement, member experience strategies and vendor accountability.
Targeted Investment and Strategy Alignment: Use assessment insights to direct resources toward contracts with the strongest opportunity for sustainable performance improvement.
Our Perspective
At ProspHire, we believe the strongest Stars strategies begin with precision, knowing exactly where you are before deciding where to go next. Through Contract insight, operational assessment and focused prioritization, create the clarity plans need to aim higher with confidence and measurable impact.
Measure. Benchmark. Improve with Purpose.
Stars improvement begins with understanding. Let’s redefine how you benchmark performance, assess readiness and elevate contract performance outcomes with a strategy built on clarity, focus and execution.
Connect with ProspHire to learn how a contract-level Stars assessment can position your plan for sustainable success.
The next phase of dental practice evolution will not be defined by the systems organizations select but by how effectively they execute.
As DSOs and DPOs continue to modernize technology, centralize operations and standardize workflows, the organizations that succeed in 2026 will be those that connect strategy to frontline delivery across their partner and affiliate practices.
Systems Integration Advisory
As DSO/DPO leaders and equity owners shift from legacy systems to fully integrated imaging, clinical and revenue management platforms, demand is rising for partners who can manage not only system selection but execution across data, people and workflows.
This includes:
Data migration and system configuration
Staff training and adoption
ROI protection during and after go-live
ProspHire Perspective:
ProspHire leads end-to-end Dental Practice Management System (DPMS) conversions using a proven framework designed to strengthen operations while minimizing risk.
Supported 160+ general and specialty practices across four national dental organizations.
Experience across general dentistry, oral surgery, pediatric, endodontics, periodontics and orthodontics.
Practices maintain or exceed pre-conversion scheduling performance through optimized templates and new workflow standardizations.
Onsite delivery supported onsite by clinical, IT and practice management specialists who understand both general and specialty dentistry.
Strategic advisory combined with delivery services enables practices to remain fully operational during go-live, improving ROI and reducing risk.
DPMS Conversion and Technology Consolidation
In 2026, successful implementations will be defined equally by the technology chosen and by the quality of training, change management and adoption. Partners who connect strategy to frontline execution will be essential.
ProspHire Perspective:
Standardized conversion methodology with consistent documentation and “repeatable processes”.
“At-the-elbow” onsite training to reduce disruption and staff turnover.
Poven ability to execute at scale.
Example:
We successfully converted nine practices in one weekend across three states, deploying a coordinated teamof 26 project management, IT, clinical and revenue cycle specialists supported by virtual command centers.
Our approach protects production, preserves schedules and accelerates value realization from technology investments.
Revenue Cycle Transformation
Revenue leakage is one of the highest-risk areas during transformation but also one of the greatest opportunities for recovery, stability and long-term savings.
Inefficient billing, missed claims, poor data integrity and weak reporting increases the demand for revenue cycle transformation services during conversion events and centralization activities.
ProspHire Perspective:
DPMS conversions paired with centralization and new automated revenue cycle vendors significantly increase risk without proper configuration and workflow oversight.
Accurate plan builds, fee schedules and practice setup are essential to prevent rejected claims. inaccurate payments and incorrect treatment plan presentations.
Delaying revenue cycle integration creates costly rework and revenue disruption.
ProspHire aligns revenue cycle workflows, centralization and vendor integration before or during DPMS conversions to protect cash flow and operational stability.
Merger and Acquisition Readiness
Clean data, standardized workflows, compliance readiness and efficient technology are increasingly central to valuation for DSOs pursuing growth or private equity investment.
ProspHire Perspective:
Supported national DSOs and DPOs in converting multi-specialty practices across multiple DPMS platforms.
What began as a seasonal campaign became something more intentional: a focused, twelve-day reflection on the pressures reshaping healthcare and the execution required to navigate them.
At a time when policy shifts, operational strain and digital transformation are accelerating simultaneously, healthcare leaders don’t need more noise. They need clarity. They need perspective. And most importantly, they need practical pathways forward.
Our “12 Days of Care & Cheer” insight series was designed to do exactly that: spotlight the realities facing health plans and providers while reinforcing the discipline, structure and follow-through required to turn strategy into results.
Twelve days of focused industry reflection created more than visibility, it created momentum. Each topic reflected real challenges facing healthcare organizations, from operational strain to digital transformation to patient access. The content didn’t just explore trends; it highlighted pain points and connected them directly to capabilities designed to alleviate friction, reduce inefficiencies and strengthen performance across the care continuum.
Turning Strategy into Stronger Outcomes
The work behind these conversations reflects a broader commitment to helping healthcare organizations achieve better health outcomes. By addressing inefficiencies, strengthening systems and supporting adoption at every level, organizations are better equipped to enhance care delivery, improve patient experiences and drive meaningful, measurable results.
At the center of every challenge and every solution are:
Patients seeking better experiences
Providers delivering care under pressure
Leaders responsible for long-term stability and innovation.
Progress in healthcare is not defined solely by systems or strategy, but by how effectively those systems empower the individuals behind them. When operational excellence and people-first execution align, meaningful and lasting improvement becomes possible.
On November 25, 2025, CMS released the Contract Year (CY) 2027 Medicare Advantage and Part D Proposed Rule, a 400+ page regulation that reaches into nearly every aspect of MA and Part D operations.
Paired with the RFI on the future of Medicare Advantage, this rule marks a true turning point in the Medicare Advantage program. We’ve been talking a lot recently about the Medicare Advantage Reset and the need for plans to take a hard look at their models for success and now CMS has acted. Through the Proposed Rule, CMS is looking to simplify the program by reducing administrative burdens for marketing oversight, while also setting the stage for bigger shifts in risk adjustment, Stars & quality bonus payments and special needs plans. Plans need to take this moment seriously and recognize we’ve moved beyond business as usual. We’re now in the next era of Medicare Advantage.
Executive Summary: Four Big Themes for Plans
From a plan and operator perspective, four primary themes stood out to us in this proposed rule and related RFIs:
A Leaner, Sharper Stars Program
After much anticipation and industry noise, CMS is finally proposing a shift away from operational obligations and toward measurable member health outcomes, proposing to remove 12 measures, introduce a new depression screening and follow-up measure. This pivot is also in line with the “MAHA” agenda from this administration.
CMs has also proposed not move forward with replacing the Health Equity Index (HEI) with the historical Reward Factor.
Given these changes, CMS simulations suggest 62% of contracts would see no Stars change, around 13% gain a half star, around 25% would lose a half star and one contract losing a full star, with around 9% gaining or losing QBP status.
CMS is explicitly asking for feedback on further simplifying the measure set and methodology while reorienting toward outcomes, prevention and healthy aging.
Targeted Deregulation and Reduced Administrative Burden
CMS proposes to rescind several recent health equity and disparities reporting requirements (UM health equity analysis, QI health disparities activities, public posting) and eliminate the Mid-Year Supplemental Benefits Notice and Multi-Language Insert/Notice of Availability.
Third Party Marketing Organization (TPMO) rules are loosened, with fewer constraints on timing and location of marketing appointments, shorter call recording retention and more flexibility in marketing language, within a “not misleading” standard.
A Deeper Look at Special Needs Plans
CMS has observed rapid growth in C-SNP and I-SNP enrollment, raising concerns that many of these members may be better served in a D-SNP, where their Medicare and Medicaid benefits can be fully integrated, something C-SNPs and I-SNPs do not provide.
The rule and RFI explore stronger state oversight of C-SNPs/I-SNPs (via SMAC-like requirements), extension of D-SNP “look-alike” policies and enhanced expectations for care coordination and integration.
Future of Risk Adjustment and Stars QBP: CMS Wants Ideas
While no new risk adjustment model is proposed for 2027, CMS devotes significant attention to an RFI on modernizing risk adjustment and Quality Bonus Payments, with an explicit focus on competition, embracing technology and leveling the playing field for smaller and regional plans.
CMS also proposes to broaden access to risk adjustment data for research and oversight, reflecting a growing emphasis on transparency, program integrity and long-term sustainability of MA.
CMS is seeking information on how artificial intelligence can be leveraged alongside current or future risk adjustment methodologies.
The Net Message: CMS is willing to pull back on some administrative and reporting requirements but only if the industry steps up with credible, data-driven proposals to advance quality, integration, transparency and member value. This program isn’t going anywhere but changes are needed to ensure its long-term viability and longevity.
Stars Ratings: A Smaller Set with Bigger Consequences: What CMS is Proposing?
Key changes to the Stars program in the CY 2027 proposed rule include:
Removal of 12 measures across Part C and D, including:
Administrative and operational measures such as appeals timeliness, appeals review, SNP care management, call center interpreter/TTY availability and plan complaint metrics.
Select clinical or process measures, including diabetes eye exam and statin therapy for patients with CVD.
CAHPS experience measures including customer service and rating of health care quality.
Addition of one clinical measure: Depression Screening and Follow-Up (Part C), reinforcing CMS’s growing focus on behavioral health.
Elimination of the Health Equity Index (HEI) or EHO4All and reinstatement of the historical Reward Factor for contract performance.
Faster, more flexible measure removal, allowing CMS to retire measures through rulemaking when low reliability, misaligned with current clinical guidance, or retired by the steward.
CMS’s impact simulations indicate:
Around 62% of contracts see no change in overall Star Rating
Around 13% gain 0.5 star
Around 25% lose 0.5 star
1 contract loses 1.0 star
Around 9% of contracts gain or lose QBP status
What It Signals
The Stars Program is not being gutted (for now). CMS even acknowledges that the technical expert panel recommended more measures, to dilute a plans ability to only focus on a handful of “critical ones”. In our opinion, CMS could be gearing up for a new plethora of outcomes based and health/behavior health measures soon. Especially in this new “MAHA” world, CMS is reinforcing clinical outcomes, preventive care and member experience as the core levers of Stars. Results based and data driven is the name of the game here. Look to measure stewards for changes to measures and new possibilities.
Implications for Plans
Every plan needs to immediately refresh and re-run Stars models with the proposed changes, including new/removed measure changes and weighting implications. A fulsome examination of vendor partnerships, strategic priorities, technology stack and intervention plan needs complete, to ensure alignment toward CMS’s signaling changes. This includes a rebalance of interventions toward high-impact clinical measures such as chronic condition management and behavioral health. Lastly, decisions are made by those who show up…engage in the RFI process, offering data on outcomes and operational feasibility.
Administrative Simplification and Targeted Deregulation
A second through-line in the proposed rule is deregulation, removing certain requirements that have grown up around MA plans in recent years.
Key Proposals
CMS Proposes To:
Modify the SEP for provider terminations, creating a straightforward SEP for Provider Terminations that begins when enrollees are notified.
Rescind communication and reporting requirements, including:
Mid-Year Supplemental Benefits Notice
Multi-Language Insert or Notice of Availability
UM Committee health equity requirements
Quality Improvement Program health disparities requirement
Loosen TPMO and marketing constraints, including:
Removing the 48-hour waiting period between Scope of Appointment and personal marketing appointment.
Allowing marketing events to immediately follow educational events in the same location.
Permitting SOA forms to be obtained at educational events.
Moving the required disclaimer from “first minute” to “before benefits discussion.
Allowing superlatives as long as statements are accurate.
Shortening recorded call retention to 6 years, or possibly 3, while keeping enrollment record retention at 10 years.
Implications for Plans. Recalibrate, don’t over-relax. Even with looser marketing timing and language rules, strong internal monitoring and oversight remain essential to ensure guardrails are clear and consistently followed. Reinvest freed resources from reduced administrative tasks into more high value areas.
D-SNPs, C-SNPs, I-SNPs, and the Next Phase of Integration
The industry has experienced an explosion of growth in C-SNP and I-SNP enrollment and CMS has noticed. In this rule, CMS provided evidence that many of these members that are dual eligible and may be better served in a D-SNP, where their Medicare and Medicaid benefits can be fully integrated, something C-SNPs and I-SNPs do not provide.
Key Provisions and Ideas
Passive Enrollment for Integrated D-SNPs
Removes the requirement for “substantially similar” networks and instead requires 120 days of continuity of care and adequate care coordinator staffing.
Continuity of Enrollment for Full-Benefit Duals
Allows D-SNPs in HIDE or coordination-only structures to maintain enrollment for full-benefit duals in Medicaid FFS.
RFI on C-SNP/I-SNP Oversight
Possible SMAC requirements for C-SNPs and I-SNPs with high dual enrollment.
Extension of D-SNP look-alike contracting limits.
New care coordination expectations and focus on mental health and substance use disorder management.
Implications for Plans. CMS expects more integration between Medicare and Medicaid, not segmentation. The more closely aligned these programs are, ultimately provides a better experience for the member. Plans should reevaluate duals portfolio strategy and model the financial and operational impact of SMAC or look-alike rules. They should also continue to strengthen state partnerships and care coordination infrastructure and embrace AI/automation technology. Lastly, plan leaders should prepare for a regulatory environment that favors integrated D-SNP over C-SNPs and I-SNPs.
Future of Risk Adjustment and Stars QBP
Although CMS did not meaningfully commit to or propose sweeping change to Risk Adjustment or Quality Bonus Payments, CMS did ask, “what should the next generation of MA payment, risk adjustment and quality policy look like?”. CMS continues to express a willingness and frankly an eagerness to hear from the industry. CMS is seeking to enhance competition and level the field for smaller and regional plans, something that has been needed for some time now. They also are seeking perspectives on how artificial intelligence can be leveraged and how to improve accuracy and integrity of risk adjustment including expanding access to risk adjustment data for research and oversight. Although not reflected in this proposed rule, make no mistake, big changes are coming for Risk Adjustment either in a future proposed rule or through a mandatory Innovation Model.
Implications for Plans. Plans should be responding to CMS’s RFI and provide data-driven comments that balance fairness, accuracy and predictability in the Risk Adjustment program. Any small or regional plan should highlight regional plan challenges and propose practical remedies. Lastly, plans should seek to link innovation and data to measurable member outcomes.
Other Notable Proposals
SNP MOC Submission moves earlier in June with two off-cycle update windows (Jan–Mar, Oct–Dec).
Part D PDE Audit Appeals gains a new three-level process with defined rights and timelines.
Strategic Roadmap for Plans
Leading organizations should act now on three fronts:
Policy and Advocacy: Create a coordinated review strategy for this proposal to ensure thorough, well-supported and meaningful comments are provided back to CMS. Respond to RFIs related to Stars measure set, duals policy, risk adjustment modernization and TPMO rules.
Analytics and Scenario Modeling: Re-forecast Stars and QBP outcomes. Map dual populations across product types and simulate regulatory changes. Quantify administrative burden reductions and plan reinvestment opportunities.
Operating Model and Governance: Refresh Stars and Quality governance to reflect outcome-focused measures. Update marketing and compliance policies for new TPMO rules. Strengthen duals integration, care coordination and continuity processes.
Closing Thought:
The reality is that the 2027 Proposed Rule for Medicare Advantage, is not simply a minor adjustment or a small tweak to a legacy program, it is the opening move in a broader Medicare Advantage reset. The convergence of new technology, a changing regulatory environment and an intensely dynamic marketplace is making it impossible to succeed using yesterday’s playbook. Product strategy, benefit design, network and care models, Stars and quality, risk adjustment, duals integration, sales and marketing, data and technology, all of it is in scope. Old models of success need to be challenged and future models of success need to be invented and operationalized now.
Read the overview here
This is the first Medicare Advantage proposal of the new administration and it is a clear signal that more structural change is coming. Stars changes are here, and more are inevitably on the horizon. Risk adjustment will be changed, the only question is when and how, not if. Through the RFIs in this rule and related Innovation Center work, CMS is explicitly asking the industry to help design the next era of Medicare Advantage. Decisions are made by those who show up and plans that engage thoughtfully, offer data driven perspectives and put forward practical ideas will be better positioned for whatever comes next. ProspHire is here to help you navigate the flurry of change and take a thoughtful, methodical approach to this new reality. We partner with health plans to reassess and modernize Medicare Advantage operating models, from Stars and risk adjustment to product and network strategy, duals and SNP portfolios, data and analytics and sales and marketing governance. We can help you game plan scenarios, quantify impact, redesign processes and craft clear, compelling responses to RFIs and proposed rules. The Medicare Advantage reset is underway. The organizations that thrive will be those willing to throw out outdated assumptions and start designing their next model of success today.
