CUSTOMER STORY
Smarter Insights, Better Outcomes:
How Aetna Improved Ratings and Care with Inovalon
Background: Aetna/CVS Health
Improving health outcomes for over 22 million commercial, ACA, Medicaid, and Medicare members nationwide requires a robust strategy. For Aetna, a part of the CVS Health family of companies, this meant combining data and technology innovation with their mission to deliver exceptional care. Facing increasingly complex regulatory benchmarks, the national health plan sought solutions to enhance quality, efficiency, and member satisfaction.
22 million commercial, ACA, Medicaid, and Medicare members nationwide
The Challenge: Enhancing Quality Metrics While Closing Care Gaps
The charge to deliver quality, timely healthcare to members while meeting regulatory requirements and performance benchmarks is a challenge every health plan faces. In Aetna’s case, the plan needed tools to:
- Simplify HEDIS® and star ratings reporting
- Accelerate identification and closure of member care gaps
- Engage members proactively with actionable insights
- Ensure accurate and complete data documentation
The stakes are high. Closing care gaps through preventative measures not only improves member health and satisfaction but plays a key role in reducing healthcare costs and securing high star ratings and quality bonus payments – key measures of success for managed care organizations. For Terance Fowler, Executive Director of Quality at Aetna/ CVS Health, “Being able to get timely information [and] care provided to our members timely during the course of the measurement year and [HEDIS season]; being able to close as many of those gaps in data utilizing the software is critical.”
The Solution: Leveraging Converged Quality for Real-Time Insights
Aetna adopted Converged Quality to transform its quality measurement and reporting capabilities. The software help plans understand current quality performance, future goals, and the right strategy to ensure success using advanced predictive analytics and benchmarking metrics. With faster data processing and improved data accuracy, health plans using Converged Quality can make informed decisions, faster, to address member needs more proactively.
For Aetna, Converged Quality empowers Fowler’s team to:
- Pinpoint member gaps in care
- Launch timely interventions to address care gaps
- Monitor and respond to data fluctuations with confidence
Speaking to the value of Inovalon’s solution, Fowler said: “Being able to accurately and completely report our HEDIS and stars rates on a regular basis, and…figure out where our gaps in care are, to help make sure that we are…providing the care to our members timely, and then capturing the data about the care…accurately. That’s awesome.”
”Being able to accurately and completely report our HEDIS and stars rates on a regular basis, and…figure out where our gaps in care are, to help make sure that we are… providing the care to our members timely, and then capturing the data about the care…accurately. That’s awesome.
Terance FowlerExecutive Director of Quality, Aetna/CVS Health
Converged Quality becomes even more impactful when paired with other solutions in Inovalon’s Converged solution suite:
- Converged Provider Enablement delivers member care gap insights and up-to-date performance data directly to providers, empowering them to act swiftly to address member care needs and meet goals.
- Converged Outreach enables health plans to create coordinated member engagement and intervention plans that address goals across quality, risk, and population health programs.
- Converged Outreach Connectors lets health plans share member data securely and seamlessly with trusted partners using APIs that support the HL7® FHIR® standard, helping advance value-based care, member engagement, gap closure, and health outcomes.
Together, these solutions enable health plans to streamline operations, proactively address member needs, and deliver on their commitment to providing high-quality, cost-effective care.
The Results: Better Star Ratings and Beyond
In a year when many plans saw their star ratings fall, Aetna was one of the few national health plans that experienced a consistent and strong improvement in ratings. According to Fowler: “A lot of that does come from our utilization of… Converged [Quality].”
Aetna is just one of several Inovalon health plan customers that saw above average performance for 2025 CMS Star Ratings. While most health plans experienced ratings decline for the third year in a row, Inovalon’s customers realized a 5% increase over the national average – with four of the seven (57%) 5-star health plans using Inovalon’s Converged Quality solution.
In addition to strong quality ratings, Inovalon’s software has helped Aetna drive improvements in other areas, including:
- Enhanced Member Outcomes: Aetna now receives more accurate data at a faster pace, enabling its quality team to make informed care decisions, quickly, and improve speed to care delivery.
- Reduced Healthcare Costs: With Converged Quality to help identify member care gaps throughout the year, more of Aetna’s members are receiving preventative care services, which will help reduce future medical costs incurred.
- Operational Confidence: The analytics software empowers Fowler’s team to trust their data and act decisively. Speaking of the impact Inovalon’s solutions have, Fowler said: “I trust the software and know it can produce an accurate result, and when we do see weird fluctuations [in the data] …I can have [my team] analyze it for me.”
When asked what he appreciates most about Inovalon’s solutions, Fowler stated: “Truly, the reliability of the software. As a long-time auditor and consultant in the industry, I’ve seen [Inovalon’s] software utilized by many payers throughout the industry. I trust it because…it’s reliable, replicable, accurate, and complete.”
Inovalon Supports Top‑Scoring Health Plans
”As a long-time auditor and consultant in the industry, I’ve seen [Inovalon’s] software utilized by many payers throughout the industry. I trust it because…it’s reliable, replicable, accurate, and complete.
Terance FowlerExecutive Director of Quality, Aetna/CVS Health
Transform Your Quality Program with Inovalon
Converged Quality is the trusted quality software for 23 of the top 25 U.S. health plans1 and analyzes over 80%2 of the nation’s clinical outcomes measurement analytics. Discover the difference the right quality solution can make on your health plan ratings and member outcomes.
1. Top 25 health plans based on AIS List of Top U.S. Payers, 2022. Inovalon internal reporting. April 2024.
2. Inovalon calculation based on HEDIS® MY2022 data. September 2023.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
HL7®, FHIR® and the FHIR [FLAME DESIGN]® are registered trademarks of Health Level Seven International. Use of these marks does not imply endorsement by HL7.
