Do Your Risk-based Contracts Get a Clean Bill of Health?

Just like members need checkups, risk-based contracts need routine monitoring, because unhealthy contracts can lose revenue due to gaps in care, documentation errors, and more. An actionable approach to value-based care — for both people and plans — makes health concerns more manageable.

Risk-based Contract Monitoring

A structure of assessment can identify where a value-based arrangement is underperforming before it costs revenue.

Step One: Know Your Settlement Position at Any Point in Time

Simple settlement tracking gives leadership an immediate, bottom-line answer to the question every risk-bearing group cares about: How much money is left in the service fund after expenses and disbursements?

A group-level view of funding, total medical expense, and distributions reflects the financial impact of each group’s contract at any time. The ability to drill into reports for funding and expense by month lets finance teams investigate any swing in balance to avoid a surprise at year-end.

Advanced settlement tracking and reconciliation may combine financial performance and quality results into a single view for real-time bonus achievement. Applying risk share and quality gate percentage earned directly against the service fund balance shows true payout, not just the raw financial position.

These two levels of settlement visibility turn a complex and contentious calculation into a transparent, monitorable process that reduces disputes between health plans and provider groups, giving both sides confidence in the final numbers.

Step Two: Identify and Prioritize Gaps in Care

Gaps in care quietly reduce quality scores and shared savings, but many organizations don’t know where they are until performance numbers are already lagging.

Prioritizing gaps starts with a high-level, real-time view of compliance with contract measures. This gives leadership a quick read on where a group, center, or physician stands on measure adherence before drilling into individual members. From there, identifying gaps may follow:

• Specific members eligible for services and the practice and PCP they are attributed to. This facilitates outreach and provider accountability.
• The highest impact measures. This view gives leaders insight into the ripple effects of noncompliance. A single overdue diagnostic can be the reason for the neglect of more than one quality measure.

Step Three: Watch the Trend Line, Not Just the Snapshot

A single month’s numbers can look fine even when the underlying trend is heading in the wrong direction.

But six months of financial activity in line graphs expose whether costs, utilization, and key ratios are moving in the right direction. Trend results expressed in both percentages and PMPM dollars show leadership whether a change is driven by a shift in cost per member or a change in active membership.

Trends surfaced this way — before settlement or year-end reporting — give organizations time to intervene, whether that means enrolling members in care management, conducting outreach to schedule visits, connecting with providers, or looking into outlier claims.

Step Four: Break Down What’s Driving Profitability for Any Population

Understanding whether a panel is profitable means little without knowing exactly what’s driving the result.

A profit-and-loss view for any population, whether that’s an entire group, a single center, or an individual PCP panel, is the financial backbone that every other reconciliation ultimately builds on. Compare funding against each expense category, then drill directly into inpatient, outpatient/ER, physician, pharmacy, and underlying claims data to investigate unexpected numbers, without requesting a separate data pull.

Step Five: Catch Funding Erosion Before It Compounds

A drop in a single member’s funded revenue rarely gets noticed, but outlier expenses can quietly compound across an entire panel.

Members whose funded revenue has shifted significantly most likely qualify for risk adjustment. Maybe a previously documented chronic condition dropped off their risk scores. Or maybe a new diagnosis has not been documented with the relevant code to meet HCC standards. Viewing lists of high-cost members with coding gaps helps providers prioritize clinic appointments to ensure payers build defensible risk-adjustment submissions and secure appropriate funding for optimal care.

Give Your Risk-Based Contracts TLC with FRG

FRG helps payers and providers stay on top of risk-based contract performance with healthcare financial intelligence solutions built for continuous monitoring.

AccuReports standardizes data in a single tool and allows financial leaders to gain immediate, real-time visibility into service fund and settlement positions while pinpointing real-time gaps in care. Organizations can catch issues while there’s still time to act.

FRG Revenue Audit and Monitoring Program (RAMP) gives users a clear view of relevant HCC and diagnosis codes for each member, highlighting both captured codes and those that still need documentation. It also flags member-level funding shifts tied to risk score changes, giving coding and finance teams a prioritized list for research.

For more information about AccuReports or RAMP, email info@frgsystems.com or call 888-466-1025 today.