For Health Plans and Their Delegates
Raise Star Ratings and get risk right.
Close care gaps, document risk with its evidence, prepare utilization reviews and reach members before costs rise. AI agents do the legwork. Your clinicians decide.
CMS raised the bar. Your team stayed the same size.
These four changes ask more of the team you have.
- Stars
Star cut points keep moving.
Last year’s thresholds are a reference, not a promise.
- Part D
Part D adherence is now risk adjusted.
All three adherence measures, from MY2026 for 2028 Stars.
- RADV
RADV now audits every contract.
CMS RADV audits now reach every eligible Medicare Advantage contract.
- Linkage
Unlinked chart review diagnoses stop counting in 2027.
CMS excludes them from CY2027 risk scores, with narrow exceptions.
Find the members who will move your rating.
Open a measure to see which practices are behind and which members have no visit. Send those members to outreach, and give each gap one owner.
Stars measure drill, from rate to member
- 1Measure
- 2Practice
- 3Members
- 4Action
- RWRobert Washington69 M · 152/94 on 08/14 · TCM day 2Not started
- FDFrank Delgado72 M · 146/92 on 06/30Not started
Work on Stars, risk adjustment and medical cost in one place.
Fold finds the members behind each measure and prepares the work for your team.
01Stars and quality
Star Ratings
Close the gaps on the measures that move your rating.
02Risk adjustment
Risk adjustment
Document each condition with the evidence a RADV review asks for.
03Medical cost
Medical cost
Reach members before their care gets expensive.
Extend care management to every risk tier.
Your care team’s hours run out at the top of the pyramid. With Fold, AI agents reach rising- and low-risk members, and nurses step in when judgment is needed.
Today
Risk tier
With Fold
Care team
Complex risk
Care team leads; AI agents prepare
Care team
High risk
Nurses lead; AI agents follow up
No one, until a hospital visit
Rising risk
AI agent outreach; a nurse follows up
A yearly reminder, at best
Low risk
AI agent reminders and screenings
The team’s hours end at the top two tiers.
Every tier has someone reaching it.
Lower medical cost by acting earlier.
Three kinds of follow-up help keep members out of the hospital. You track the effect against your own MLR baseline.
Delegate oversight, checked every morning
Follow up after every discharge
Each eligible discharge gets an owner and a follow-up deadline.
Care managementCatch rising risk early
Wellness visits, screenings and chronic care follow-up for rising-risk members, with evidence.
Care gap closurePut high cost members first
Your own data surfaces high cost and rising-risk members for care management first.
Population intelligence
What changes when you reach every member.
We measure these with you, against your own baseline.
More members seen
Rising- and low-risk members get outreach, a visit and a follow-up.
More accurate documentation
More visits mean more conditions documented with their evidence.
Fewer avoidable admissions
Discharges and early warning signs get an owner before an ED visit.
Fewer members moving up a tier
Track whether earlier outreach keeps rising-risk members out of the high-risk tier.
Questions plan leaders ask.
How AI agents and approvals workHow does Fold support a HEDIS audit?
Each record keeps its source document, date of service, provider and review history. Your plan and auditor decide whether it meets the reporting rules.
Will Fold add more requests for our providers?
No. Fold merges plan requests into one packet per patient, attached to a visit already booked.
What stands behind each suggested diagnosis?
A cited source. The treating clinician decides what to document, and a certified coder reviews additions and deletes before submission.
Can Fold speed up reviews without automating denials?
Yes. Fold matches chart evidence to your criteria and tracks each deadline. Your authorized reviewers make every determination.
Can AI agents reach members without crossing into marketing?
Yes. Care outreach stays separate from marketing. Fold checks recorded consent and opt outs before every message, and your compliance team sets contact windows.
Case studies
See it in a case study.
Value-based care networksHow a care network builds SNP care plans from health risk assessments
Every special needs plan member needs a care plan built from their assessment. Keeping up is the hard part.Get the case study
Provider networksHow a California MSO follows up faster after hospital discharge
The days after a hospital discharge, and the race to reach each patient before something goes wrong.Get the case studySee how Fold supports
Star Ratings and Risk Adjustment.
See one workflow run across every risk tier.
Book a demo