A new operating standard for D-SNP
Regional and community plans are stuck in their markets — and losing money on D-SNP. DualWorks makes the economics work: launch, comply, compete.
The Gap
Look-alike plans phase out as CMS lowers the threshold to 60%, forcing plans toward compliant D-SNP paths.
Medicare growth becomes tied to Medicaid alignment, making enrollment coordination a core operating requirement.
Alignment becomes the floor, requiring plans to operate Medicare and Medicaid as one integrated model.
States are raising expectations through SMACs, deeper integration requirements, and stronger operational accountability.
Plans lose margin acting on last quarter's data.
Data remains retrospective, chasing the care. Compliance requests an extract. Data team reconciles systems that disagree. Care Management acting on a 4-week old report, leaving gaps:
RAF Leakage
Per 1,000 lives. FQHC undercoding leaves risk-adjusted revenue uncaptured.
Admin Spend
Spent proving the work. CM documents, Compliance assembles, Data reports.
Stars Drag
Measures stall when ownership is split across four separate teams.
Policy Updates
CMS keeps moving while plans track execution in Word and email.
The platform
Every D-SNP commits to CMS how it will identify, assess, manage, and coordinate care for its members. Most plans file that commitment and never operationalize it.
DualWorks makes the Model of Care a living system — member-level data driving the daily actions those commitments require.
When data drives the care, compliance and quality follow.
Click a capability to see how it runs in practice ↓
Use Cases
The plan finds out too late — so care costs more than it should, and proving the care costs more than that.
Providers are paid on CPT codes, so diagnosis coding is an afterthought — worst where the provider is capitated. Conditions get treated and documented, never coded, and the plan is paid below its real risk.
Data in
DualWorks assist
AI Encounter-Linked Review
Reviews encounter notes & linked records
Surfaces treated-but-uncoded diagnoses and unsupported codes already submitted
Data & workflow out
Recommended adds and deletes
Prioritized review queue
Routed to coders & providers
Every decision logged, encounter link attached
Adds and deletes, both. Accurate coding, not upcoding.
Medication adherence misses the benchmark again. Outreach, rewards, and provider education all launch — and nobody can say which one worked.
Data in
DualWorks assist
AI Stars Tracking
Automatic monitoring of
process & outcome measures
Tracks CAHPS survey progress
and analyzes results
Data & workflow out
Recommended next steps
Assigned to the right teams
Documentation evidence captured
Gap closures tracked by intervention
Know what moved the number.
Care management documents the work. Compliance asks the data team for an extract. The data team reconciles systems that disagree. A report comes back four weeks later saying what should have happened. Every hour of that is spent proving care already delivered — and the documentation still gets rebuilt by hand at audit time.
Data in
DualWorks assist
AI Evidence Engine
Traces HRA → ICP → ICT → transitions
at the member level
Captures evidence as the work happens
Maps new CMS and state guidance
against the policy library
Data & workflow out
HRA & care plan completion queues
Evidence file per MOC commitment
State deliverables tracked alongside federal
Delegate oversight packets, on the plan’s standard
Members flagged before they fall through
Audit dry run on demand
Nobody assembles evidence. The work already did.
States layer care management mandates on D-SNPs through their Medicaid agency contracts — new populations, in-person requirements, specialist training, separate deliverables. None of it appears in a CMS universe.
Data in
DualWorks assist
AI Policy Mapping
Parses new guidance
against your policy library
Flags every impacted P&P, owner & deadline
Data & workflow out
Recommended P&P changes to owners
Impact analysis to guide decisions
MOC change pushed to impacted functions
Attestations & evidence tracked
New guidance, operationalized.
Built to Compete
Regional, community-rooted, health system-owned, and public plans are being asked to run D-SNPs with the complexity of United or Humana.
DualWorks gives them the operating layer to keep members from falling out of the care model, cut the hours spent proving it, and capture the revenue their real risk supports — without adding a second system for anyone to work in.
Intuitive by design
A UI your teams actually want to open — clear queues, plain language, no analyst required.
Not rip-and-replace
Start with one workflow. Prove value and get buy-in before expanding across teams and programs.
Works where your teams work
Recommendations and tasks can route through email, Teams, or Slack — powered by DualWorks.
Amy Wang
Amy built Medicaid operations at Malama Health (YC S22), scaling from zero to $3M+ ARR across 15 Medicaid MCOs within 18 months.
Previously managed enterprise Mental Health Parity governance at Health Care Service Corporation across legal, clinical, product, UM, and network teams. She holds an MPA from the University of Wisconsin-Madison.
We'll run a live demo using a sample plan profile. No customer data required.