ACO REACH organizations require a specific set of tools that enrich and analyze data to produce insights that power care management workflows with coordinated EHR-embedded decision support. Additionally, the capitated payment structure of ACO REACH requires core claims administration technology that manages attribution and eligibility, as well capitation claims processing, reconciliation, and payment to network providers.
Most legacy software systems don’t have these capabilities, although some software providers have tried to tack on these capabilities through application programming interfaces or patches to a legacy system. When ACOs try to incorporate payment technology and analytics tools built for a value-based care future with legacy systems designed in a fee-for-service world, the result is a system that is costly to license and maintain. Additionally, storing data across multiple point solutions increases the security risks of data breaches for critical patient and organizational data.
A modular system designed specifically for value-based models like ACO REACH gives organizations the ability to streamline data and technology infrastructure and efficiently coordinate interconnected workflows designed to act on insights. Cedar Gate designed our software for the demands of a value-based care future. Our Data, Analytics, Care, and Payment technology can uniquely enable and support advanced VBC models.
Critical Tasks: Processing CMS Files, Area Deprivation Index (ADI), and Medicare Benchmark Data
Cedar Gate’s data ingestion process pulls together disparate data from multiple sources, including CCLF, CRF, and beneficiary alignment files from the Centers for Medicare and Medicaid Services (CMS). These tools help an ACO REACH organization maintain accurate beneficiary roles for appropriate care management and accurate reimbursement. Additionally, the ability to incorporate data from sources like the ADI provide a more complete picture of beneficiaries’ needs to help with outreach and closing care gaps.
Critical Task: Contract modeling
CMS is continually innovating with new value-based care models, and many commercial payers follow suit. Organizations need tools to help evaluate new ACO models and determine which one(s) will provide the most benefit for patient populations, and for operational efficiency and financial viability. Cedar Gate’s contract modeling tools use historical data and information from your existing patient population to forecast performance in a wide variety of VBC models.
Critical Task: Identify high-performing providers for risk-sharing arrangements
A high-performing network of providers is critical to success in shared risk agreements. Cedar Gate analytics help evaluate provider performance and identify those whose performance most closely aligns with the goals of existing or future VBC arrangements. You can also use it to evaluate providers already in a network, presenting them with in-depth data to back up performance evaluations.
Critical Task: Create and report on health equity plans
Health equity plans are an essential part of ACO REACH, and are likely to become a big part of other advanced alternative payment models in the future, such as ACO Primary Care Flex. Cedar Gate’s analytics software pulls critical data from CMS and other sources to help organizations build an effective health equity plan, and quickly report on it to satisfy compliance requirements.
Critical Task: Report on capitation payment reconciliations
Capitated payments are a dramatic divergence from the fee-for-service claims that were the norm in healthcare for several decades. Detailed reports from Cedar Gate’s analytics software can show capitation payment reconciliations in an easy-to-read format so providers and administrators throughout your ACO REACH network feel confident that payments are accurate.
Critical Task: Analyze variations in HCC/RAF coding
Variations in HCC and RAF coding can impact risk scores, as well as impacting patient care and reimbursements. Cedar Gate’s analytics software brings together multiple data sources and can quickly reveal disparities or variations in HCC and RAF coding. ACOs can use this information to reconcile scores and ensure accuracy for every aligned beneficiary.
Critical Task: Create workflows to execute on health equity plans
Once an ACO creates a health equity plan, the next critical step is acting on it to improve care and access for underserved patients within a population. Cedar Gate’s integrated solutions transfer information seamlessly from the analytics tools where you built the health equity plan, to the care tools where the information is translated into workflows for care teams.
Critical Task: Collect SDoH data
The point of care is a critical moment when providers and care teams can collect information on social determinants of health. Cedar Gate’s care software makes it easy to capture this information in a patient’s record. The information is shared seamlessly between analytics and care applications, so everyone is working from the most accurate and up-to-date SDoH information set.
Critical Task: Incorporate HCC & RAF scoring into point of care workflows
When providers can quickly access HCC and RAF scores at the point of care, they can identify gaps and ensure these scores are updated each year. That information is available in Cedar Gate’s care solutions so providers don’t have to log into multiple systems to find that information, or risk missing out on HCC and RAF scoring opportunities when a patient is in the exam room.
Critical Task: Process complex capitated payments
Capitated payments are dramatically different, and far more complex, than fee-for-service claims. Processing these payments accurately requires a payment technology solution specifically built for alternative payment models. Cedar Gate’s capitation engine is an efficient, flexible, proven tool for managing and processing these claims.
Critical Task: Distribute capitated payments to appropriate ACO providers
After an ACO processes a capitation claim and receives payment, the next step is figuring out how to distribute that payment across all the providers and care teams that participated in a patient’s care. Cedar Gate’s capitation software can be configured with specific details on any capitation arrangement, and automatically calculate distributions for downstream providers according to any VBC contract parameters.
ACO REACH organizations need a tech stack built specifically for the unique needs of advanced value-based care models. Only Cedar Gate has the full solution, with integrated applications that seamlessly share data and improve your ability to care for your ACO patient population. Start building your customizable ACO REACH solution today.
