Business challenge

Slow access to medical data can have a significant impact on healthcare organizations’ ability to meet evaluation and audit deadlines, potentially exposing them to millions in lost revenues and penalties annually.


Molina Healthcare centralized its medical records in a single repository with integrated case management and automatic coding for medical charts, using IBM Enterprise Content Management solutions.



faster access to medical chart data makes it easier to meet deadlines


reduction in diagnostic coding errors improves report quality


equal to 4 FTEs achieved by automating chart-coding for a specific initiative

Business challenge story

Meeting tight deadlines

As a Medicare plan provider, Molina Healthcare is subject to rigorous evaluations and audits from the Centers for Medicare and Medicaid Services (CMS). Every year, CMS rates health plans using a five-star system. Ratings are based on a number of measures, such as the ability to effectively coordinate care, manage chronic illnesses and improve member retention. Rohit Gupta, IT Manager at Molina Healthcare, explains, “Star ratings play a crucial role in helping Molina Healthcare to maintain its Medicare contract with CMS and determine the level of payment incentives that we receive from federal programs.” A significant portion of the quality measures that contribute to the star ratings report is calculated using data from the Healthcare Effectiveness Data and Information Set (HEDIS) – a tool used to measure performance on important dimensions of care and service. Each year, Molina Healthcare is given a strict timeline to submit HEDIS rate calculations and source validations for selected plan members to CMS. Molina Healthcare must collect medical records for as many of its selected members as possible within a five-month period. Due to the volume and complexity of the organization’s medical charts, as well as the time required to manually search for pertinent performance data, Molina Healthcare estimated that it completed fewer than half of its targeted pursuits in any given year. This meant that the organization was potentially losing out on opportunities to boost its star rating and qualify for greater bonus payments. To add to the challenge, Molina Healthcare is required to respond to annual CMS claims audits. If the organization cannot provide the requested information to CMS within specified deadlines, it can be subjected to penalties of close to USD20 million.  

The IBM solutions allow Molina Healthcare to work more effectively, and set us up for delivering great quality care and solid financial results.

—Rohit Gupta,IT Manager,Molina Healthcare

Transformation story

Centralizing medical chart data and streamlining management

With potentially millions of dollars on the line, Molina Healthcare knew that it needed to find a better way to access complex medical chart data and streamline HEDIS rate calculation processes. The company teamed up with IBM Business Partner Datum Consulting Group to overhaul case management practices with a suite of IBM Enterprise Content Management and IBM Business Analytics software. Within a tight four-month schedule, the project team worked to centralize medical records and integrate case management of charts into the company’s HEDIS and Risk Assessment and Management Program (RAMP) infrastructures. Using IBM® Case Manager, Molina Healthcare created a single, centralized repository for medical charts and other unstructured medical information sources, increasing transparency of data across the organization while reducing content redundancies and inconsistencies. Authorized users can request files through a chart target list, making it quick and easy for staff to access the information they need. “We handle a huge volume of medical chart information – for HEDIS alone we work with around 300,000 medical charts a year – and the IBM Enterprise Content Management tools are proving to be a huge asset when it comes to storing files and making them easily accessible,” comments Gupta. “Even for our larger charts that are around 400 MB, it only takes about three minutes to retrieve the information.” Thousands of files are automatically entered into the repository and indexed on a daily basis, using IBM Case Manager and IBM Content Collector for Files software. Molina Healthcare also uses IBM Forms Server software together with IBM Case Manager to automatically code medical charts, saving time and reducing the risk of human error.  

Results story

Faster access to more accurate information

Since implementing the IBM solutions, Molina Healthcare has considerably accelerated access to medical chart data and improved the quality of this information by eliminating a large amount of coding errors. By increasing the accuracy and timeliness of the information it provides to the CMS and other agencies, Molina Healthcare can better mitigate the risks of failed audits and associated penalties, as well as increase its quality ratings in the industry. “Staff can access medical chart data in about half the time that it took in the past, which makes it much easier for us to meet deadlines for submitting CMS audit and HEDIS rate calculation documentation,” notes Gupta. “We have also reduced the number of chart coding errors by 25 percent, which saves us from having to go back and make corrections and ensures that the information we submit is highly accurate.” An unanticipated benefit of the IBM solution is that Molina Healthcare can now use the automated medical chart target list workflow to track vendor performance and measure the productivity of internal coders in meeting audit and compliance timelines. The organization has already realized significant savings by using this information to improve operational efficiency. Gupta concludes, “We are very impressed by the results we have seen so far, and our success has sparked a lot of interest from other departments around adopting IBM content and case management software. The IBM solutions allow Molina Healthcare to work more effectively, and set us up for delivering great quality care and solid financial results.”  

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About Molina Healthcare

Molina Healthcare, Inc. offers health plans, clinical care and health information management to families and individuals covered by Medicaid, Medicare and other government-funded programs. Headquartered in Long Beach, California, the company serves nearly two and half million people in 11 states.

Solution components

  • Case Manager
  • HC: Analytics and Reporting
  • HC: Collaborative Care and Health Information Exchange
  • HC: Provider Transformation

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