AI-Powered CMS Star Ratings Improvement & HEDIS Measure Optimization System

Core Logic

The Orchestrator Agent serves as the central command and control system for the entire campaign creation workflow. It decomposes the mission into discrete tasks, routes work to appropriate specialized agents, monitors progress across all parallel and sequential operations, handles inter-agent communication through a structured messaging protocol supporting request, response, broadcast, and handoff message types, manages error recovery and retry logic, and provides real-time status updates on overall mission completion. The agent maintains awareness of agent dependencies and ensures proper execution order while maximizing parallelization where possible. Core capabilities include task decomposition and planning, agent routing and load balancing, progress monitoring and status reporting, error recovery and graceful degradation, inter-agent message coordination, and execution timeline management. Status tracking states include IDLE, RUNNING, COMPLETED, and FAILED. Collaboration protocols support sequential execution, parallel execution, and consensus building patterns.

Core Logic

The Analyzer Agent ingests and processes healthcare data from six primary sources (EHR, claims, pharmacy, eligibility, engagement, survey) through a sophisticated data pipeline with five stages: Ingestion, Validation, Transformation, Enrichment, and Anonymization. It performs advanced analytics including propensity scoring for engagement likelihood, care gap prioritization based on star rating impact, risk stratification, medication adherence analysis, and CAHPS survey sentiment analysis. The agent identifies patterns across HEDIS measures and correlates member characteristics with successful gap closure outcomes. It produces detailed analytical outputs including member segments with demographic profiles, risk scores, and predicted responsiveness to different intervention types. Core capabilities include multi-source data ingestion and validation, HEDIS measure analysis and scoring, care gap identification and prioritization, member risk stratification, engagement propensity modeling, and data quality assessment with impact analysis. Data sources processed include EHR, Claims, Pharmacy, Eligibility, Engagement, and Survey systems. Output types include propensity scores, care gap analysis, member segments, and risk profiles.

Core Logic

The Designer Agent synthesizes analytical insights from the Analyzer Agent to create comprehensive, personalized campaign strategies. It designs multi-channel campaign journeys with optimized touch sequences across Email, SMS, Print, Phone, and Web channels, determines optimal messaging content tailored to member segments and SDoH factors, creates personalized content variations addressing specific barriers (transportation, language, financial, housing, health literacy), and establishes campaign timelines aligned with HEDIS measurement periods. The agent outputs detailed campaign specifications including target member lists, projected gap closures, channel mix allocations, and AI-generated explanations for each strategic decision. Campaigns are designed to address healthcare disparities and promote equity across diverse populations. Core capabilities include multi-channel journey design, personalized content strategy, SDoH-informed messaging, channel mix optimization, timeline and sequencing, and equity-focused campaign design. Personalization factors considered include demographics, risk scores, care gaps, SDoH barriers, and engagement history.

Core Logic

The Predictor Agent employs Monte Carlo simulation with configurable iterations (default 10,000) to generate risk-adjusted outcome projections with confidence intervals. It models campaign performance scenarios considering historical response rates, seasonal factors, competitive dynamics, and member population characteristics. The agent produces detailed forecasts including projected star rating improvements, expected gap closures by HEDIS measure, estimated revenue impact from CMS bonus payments, and ROI calculations. Predictions include pessimistic, expected, and optimistic scenarios with associated probabilities, enabling informed decision-making. The agent continuously updates predictions as campaign execution data becomes available, improving forecast accuracy over time. Core capabilities include Monte Carlo outcome simulation, confidence interval calculation, star rating improvement projection, revenue impact modeling, scenario analysis (pessimistic/expected/optimistic), and dynamic forecast updating. Simulation parameters include iteration count, confidence level, historical response rates, and seasonal adjustments. Output metrics include star rating delta, gap closure rate, revenue impact, ROI, and cost per gap closed.

Core Logic

The Optimizer Agent monitors campaign execution in real-time and autonomously implements optimizations when performance metrics cross predefined thresholds. It analyzes response rates, engagement patterns, and gap closure velocities across all channels and member segments. When underperformance is detected, the agent executes autonomous actions including channel reallocation (shifting budget from underperforming to high-performing channels), message optimization (testing alternative content), audience refinement (expanding or contracting target segments), budget reallocation (redistributing funds based on ROI), and timing adjustments (modifying send schedules). Each autonomous action includes a detailed reasoning chain with confidence scores, and actions can be configured to require human approval above certain impact thresholds. The agent maintains rollback capabilities for all optimizations. Core capabilities include real-time performance monitoring, autonomous channel reallocation, message A/B testing and optimization, audience segment adjustment, budget redistribution, and timing optimization. Optimization types include channel shift, message change, audience refinement, budget reallocation, and timing adjustment. Autonomy features include threshold-based triggers, confidence scoring, reasoning chain transparency, human approval gates, and rollback capabilities.

Core Logic

The Compliance Agent validates all campaign components against regulatory requirements throughout the campaign lifecycle. It performs automated checks for HIPAA compliance (PHI handling, minimum necessary rule, business associate requirements), CMS marketing guidelines (Medicare communication rules, required disclaimers), consent management (preference verification, opt-out processing), and data governance (PII masking, data retention policies). The agent maintains an immutable audit log with cryptographic hashing for regulatory verification, tracks all data access and modifications, and generates compliance reports for audit purposes. It flags potential violations before campaign deployment and can halt execution if critical compliance failures are detected. The agent ensures all AI-generated content meets regulatory standards and maintains documentation of all compliance decisions. Core capabilities include HIPAA compliance validation, CMS guideline enforcement, consent and preference verification, audit trail generation, compliance reporting, and violation prevention. Compliance frameworks include HIPAA, CMS Marketing Guidelines, State regulations, and Organizational policies. Audit features include immutable hash chains, complete data lineage, access logging, modification tracking, and regulatory report generation.