Payment Technology to Power Alternative Payment Models in ACO REACH

For decades, healthcare organizations have operated under a fee-for-service (FFS) model where claims are paid based solely on the volume of services provided in the course of patient care. These models are filled with perverse incentives that do nothing to improve overall patient health. However, we persist in using FFS models because we’ve grown accustomed to them, and because payment technology software is designed around these models.

With the launch of ACO REACH in 2023, organizations must now be able to process capitated payments. This requires a significant shift in claims adjudication. Organizations serving the ACO REACH market still using legacy software designed around FFS payments will quickly get frustrated with how much manual work is required to pursue APMs.

Rather than try to make a legacy FFS payment system work for value-based care claims, Cedar Gate built a solution uniquely designed with the capabilities for administering APMs like capitation.

That includes the capabilities to:

• Ingest CCLF, CRF, Alignment Files, and capitation transactions into a common data lake
• Process capitated payments from CMS and distribute sub capitation to network providers
• Conduct funds flow and payment reconciliation analytics to determine contract performance and profitability

To succeed in these models, healthcare providers need software that identifies risk in a patient population, then highlight opportunities to improve care and reduce total costs. The ability to tie cost and quality together drives better outcomes and helps providers find the optimal solutions for managing patient health – getting them the right care, in the right place, at the right time, with the right provider. Payers and providers also need data to support quality performance and maximize the financial benefits of these contract arrangements.

For many organizations, the path toward capitation will take time. Cedar Gate’s composable tools allow you to choose the specific pieces that make sense today based on where you are in the VBC payment journey, then expand your capabilities over time as you become more comfortable and familiar with APMs.

Contact us today to learn more about how our payment technology solution will save you time and effort and improve your financial performance in ACO REACH.