Documentation & Methodology Center — Maven Healthcare Intelligence

Tukey 3.0x IQR Outlier Deletion & Cut-Point Calculus

Under the CMS 2024 Medicare Advantage Final Rule (CMS-4201-F), CMS codified Tukey outlier deletion using 3.0 times the Interquartile Range (IQR) outer fences across non-CAHPS Star Ratings measures.

Mathematical Formulation: Tukey Outer Fences Authority: 42 CFR § 422.166(a)(2)(i)

F_lower = Q1 - 3.0 * (Q3 - Q1)
F_upper = Q3 + 3.0 * (Q3 - Q1)
Valid Domain: Any score x < F_lower OR x > F_upper is permanently deleted prior to mean clustering.

After Tukey deletion, measure cut points are derived using 10-iteration hierarchical mean clustering, bounded by the statutory 5% guardrail cap preventing non-CAHPS cut-point thresholds from drifting more than 5 percentage points from the prior Star Year.

Why Incumbent Black Boxes Fail

Legacy consulting shops simulate cut points by applying uniform Gaussian shifts. Maven executes deterministic SQL clustering directly against the 95,967 CMS historical measure observations in DuckDB, allowing actuarial teams to model the exact effect of Humana and UnitedHealth contract consolidations on national cut boundaries.

Dynamic QBP Rebate & Benefit Liquidity Engine (QBP-BLE)

Quality Bonus Payments represent the single largest financial determinant of regional Medicare Advantage competitiveness. Under SSA § 1853(o), contracts achieving 4.0 Stars or higher receive a statutory +5.0% benchmark rate increase (+10.0% in qualifying double-bonus counties under SSA § 1853(o)(5)), while statutory rebate retention under 42 CFR § 422.266 / SSA § 1854(b)(1)(C)(v) steps from 65.0% (3.5★–4.0★) up to 70.0% (4.5★–5.0★) and drops to 50.0% at ≤ 3.0★.

Overall Star Rating	Benchmark Bonus Factor	Statutory Rebate %	Competitive Impact
4.5★ – 5.0★	+5.0% QBP Benchmark Bonus (+10.0% Qualifying Double-Bonus County under SSA § 1853(o)(5))	70.0% Rebate Retention	Maximum statutory rebate retention; funds rich $0 premium, dental, vision, and OTC allowances
4.0★	+5.0% QBP Benchmark Bonus (+10.0% Double-Bonus County)	65.0% Rebate Retention	Full QBP benchmark uplift with standard 65.0% statutory rebate retention
3.5★	0.0% QBP Benchmark Bonus (QBP Cliff)	65.0% Rebate Retention	Loss of 5% / 10% QBP benchmark uplift ($35–$75 PMPM); forced benefit retrenchment
≤ 3.0★	0.0% QBP Benchmark Bonus	50.0% Rebate Retention (15-Point Statutory Rebate Cliff)	Compound loss of QBP uplift and 15-point rebate retention compression; acute enrollment churn

Annual Contract Quality Bonus Exposure Formula Authority: Social Security Act § 1853(o) & 42 CFR § 422.266

Annual Cliff Exposure = Σ_{county} [ Enrollment_{county} * Benchmark_{county} * 0.05 * 12 ]

Maven ingests CMS 2026/2027 County Benchmark Rate Books across all 3,243+ US counties. Every dollar calculated in the Maven analytical engine reflects the contract-specific weighted county benchmark multiplied by verified monthly enrollment.

CMS Time and Distance Network Adequacy (42 CFR § 422.116)

Under 42 CFR § 422.116(b), (d)(2), and (d)(4), CMS evaluates Medicare Advantage network adequacy across 27 provider specialty types and 13 facility types (40 total Health Service Delivery [HSD] categories), requiring plans to demonstrate that at least 90% of beneficiaries in Large Metro and Metro counties, and at least 85% of beneficiaries in Micro, Rural, and Counties with Extreme Access Considerations (CEAC) reside within maximum travel time and distance standards (subject to the 10-percentage-point telehealth credit under 42 CFR § 422.135).

-- Maven Acute Delivery & Outpatient Exclusion Audit (42 CFR § 422.116)
SELECT
    c.fips_code,
    c.county_name,
    c.state_abbr,
    c.total_hospitals,
    c.acute_care_hospitals,
    c.emergency_department_hospitals,
    c.pct_hospitals_with_emergency,
    COUNT(DISTINCT h.facility_ccn) FILTER (WHERE h.cms_hospital_star_rating >= 4) AS high_quality_hospitals,
    (SELECT COUNT(*) FROM core.nucc_hospitalist_exclusions WHERE is_hospital_employed_exclusion) AS excluded_inpatient_taxonomies
FROM core.fct_county_hospital_capacity c
LEFT JOIN core.dim_hospital h USING (fips_code)
GROUP BY
    c.fips_code, c.county_name, c.state_abbr,
    c.total_hospitals, c.acute_care_hospitals,
    c.emergency_department_hospitals, c.pct_hospitals_with_emergency;
        

Master Provider Index & Specialist Hospitalist Exclusion

A common pitfall in healthcare provider analytics is confusing inpatient facility hospitalists with community ambulatory specialists. Including hospital-employed facility staff in outpatient adequacy counts falsely inflates network strength.

Maven isolates 5,419 certified Medicare hospitals from official CMS open data (dataset xubh-q36u), mapping facility CCNs, staffed beds, and 24/7 emergency departments. We strictly exclude NUCC inpatient hospitalist taxonomies (207RH0003X) when evaluating outpatient specialty parity.

Executive Cockpit Progressive Disclosure Architecture

The Maven platform is built on Edward Tufte's principles of data density and progressive disclosure. The interface moves from high-level C-suite synthesis down into micro-level actuarial evidence in three intuitive layers:

Layer 1: The Executive BLUF & Cliff Metrics

Immediate summary of current Star Rating, projected 2027 rating, net revenue cliff exposure, and top 3 volatile measures.

Layer 2: Head-to-Head Measure Distribution

Side-by-side plan comparisons sorted by measure weight (5x CAHPS down to 1x Admin) with horizontal split differentials.

Layer 3: The Actuarial Lineage Drawer

Clicking any metric opens the lineage drawer, displaying the exact SQL query, CMS source table SHA-256 hash, and cut-point sensitivity range.

Head-to-Head Cut-Point & Care Gap Calculus

Rather than displaying abstract Star glyphs, the Cut-Point Matrix translates measure percentiles into exact patient care gaps.

Patient Care Gap Volume Formula

Care Gap Volume = CEIL [ (Cut_Point_{Star+1} - Current_Score) * Eligible_Member_Denominator ]

Example: On Part D Medication Adherence for Diabetes (3x weight), if Contract H3359 is at 83.2% and the 4-Star cut point is 84.1% with 14,200 eligible diabetics, Maven specifies: "Close exactly 128 patient care gaps to capture +0.150 weighted stars."

Three-Point Contract Health Audit Protocol

Actuarial and quality leaders can conduct an instant, deterministic health audit of any Medicare Advantage contract using this standardized 3-step evaluation:

Baseline Enrollment & Footprint Audit: Validate active county-level contract enrollment against verified CMS monthly CPSC records to establish accurate member denominators across each service market.
Clinical Measure Sensitivity Audit: Identify high-weight clinical measures (3x and 5x CAHPS) operating near cut boundaries, calculating the exact patient care gap volume required to defend or capture rating tiers.
Threshold Proximity Analysis: Evaluate contract summary score distance to statutory half-star rounding thresholds (e.g., assessing distance to the 3.750 rounding threshold to secure 4.0 Stars and statutory Quality Bonus Payments).

Actuarial Excel (.xlsx) & Executive Board Deck (.pptx) Exports

Every screen on Maven exports deterministically into audit-grade offline deliverables:

Sheet 1: Executive BLUF — Summary scores, contract ratings, and QBP revenue stakes.
Sheet 2: Measure Cut-Points — Raw scores, star cut-bands, and Tukey distribution metrics.
Sheet 3: Care Gap Calculus — Exact patient gap volumes for 4.0+ Star bonus capture.
Sheet 4: V28 RAF Transition — County risk score deltas and benchmark revenue drag.
Sheet 5: Rebate Sensitivity — Part C rebate retention tiers (70%/65%/50%) and bonus curves.
Sheet 6: County Market Share — Multi-county enrollment, penetration, and HHI competitor concentration.
Sheet 7: Plan Benefit Packages — PBP benefit richness, copays, MOOP, and OTC allowances.
Sheet 8: DIAP Provenance Lineage — Cryptographic SHA-256 manifests, SQL queries, and statutory citations.

Data Integrity & Assurance Protocol (DIAP)

Maven is governed by strict mathematical and cryptographic standards. We enforce a zero-hallucination policy across the entire platform:

[MAVEN DIAP STANDARD]
ZERO ORPHAN NUMBERS: Every number carries a verified [C-###] lineage claim.
DIAP DETERMINISTIC GROUNDING: All arithmetic is executed in DuckDB SQL or Python numpy/pandas.
IMMUTABLE SOURCE LINEAGE: 130 CMS files verified via SHA-256 manifests.
DETERMINISTIC VERIFICATION GATE: Release blocked unless 'make verify' passes.
        

Zero-Egress Security & HIPAA Compliance

Because Maven operates exclusively on official CMS open data, federal rate books, and public provider registries:

No Protected Health Information (PHI) Ingested: Zero patient names, claims, or personal data enter Maven.
No Business Associate Agreement (BAA) Required: Enables immediate deployment and simplified compliance review, as zero protected health information (PHI) is processed.
Zero-Egress Architecture: Analytical models run on dedicated, isolated cloud infrastructure (DigitalOcean VPS + Caddy TLS).

Frequently Asked Questions (Health Plan C-Suite & Actuaries)

How does Maven differ from legacy vendors like Inovalon or Cotiviti?

Legacy vendors sell retrospective claims-aggregation software that takes 6 months to implement and acts as an opaque black box. Maven is an objective, immediate competitive intelligence layer built entirely on official CMS open data with full SQL lineage. You receive actionable, forward-looking cut-point simulations on Day 1 without uploading a single internal file.

How often is the underlying data refreshed?

Maven runs automated ingestion monitors scanning CMS release pages. Star Ratings data is updated annually upon CMS October release; monthly CPSC contract/plan enrollment is updated within 48 hours of CMS publication; Rate Books and Provider Files are continuously synchronized under immutable SHA-256 manifests.

Can our internal actuarial team audit the underlying SQL models?

Yes. Transparency is our core value proposition. Every chart on Maven provides an audit drawer displaying the exact SQL query, execution timestamp, and source file lineage. Our 8-sheet Actuarial Excel export contains live cell formulas, allowing your actuaries to verify the math independently.

What is the Executive Contract Health Diagnostic?

A comprehensive analytical evaluation of a contract's quality standing, cut-point vulnerabilities, and county-level revenue exposure. Generated directly from verified federal tables and rate books, the diagnostic provides leadership with immediate visibility into distance to rating thresholds, critical leverage measures, and Quality Bonus Payment liquidity stakes without requiring months of custom data integration.

Maven Methodology & Actuarial Defensibility Center