Use Case 1
Weekly Performance Refresh
Trigger: Claims run-out data arrives
1.Ingest claims with IBNR adjustment
2.Recalculate YTD PMPY and utilization trends
3.Project year-end position against benchmark
4.Update risk corridor standing
5.Identify cost drivers and outliers
6.Model intervention scenarios
7.Generate leadership dashboard
✓
Finance and VBC leadership see live contract performance, not a quarter-old report.
Use Case 2
Intervention ROI Modeling
Trigger: Proposed care management initiative
1.Identify target population
2.Estimate intervention cost
3.Model expected utilization/cost impact using historical patterns
4.Calculate near-term and 18-month ROI
5.Include quality-bonus tier-movement probability
✓
Leadership makes intervention decisions with math, not gut feel.
Integrations
Claims Data Warehouse
CMS Shared Savings Files (MSSP, REACH)
Benchmark Data
Care Management Platform
Executive BI Dashboard
Industries
healthcare
See It In Action
A sample conversation with this agent
Where do we sit against our shared savings benchmark this month?
YTD PMPY cost: $8,420 vs. benchmark $9,180. Projected year-end: $9,045 vs. benchmark $9,210 — approximately $2.4M in projected shared savings at our 60% split = $1.44M to the ACO. Trajectory is favorable but tight; we're within the risk corridor. Main positive drivers: ED utilization down 14%, ACS admissions down 22%. Main risks: specialty drug trend running 18% above forecast and a spike in late-year elective procedures could compress the margin.
Who are our top cost outliers?
Top 20 members account for 31% of total spend. Breakdown: 8 oncology (mostly appropriate), 5 complex CHF with frequent readmissions (care management opportunity), 3 ESRD (fixed cost), 2 recent major surgeries with unexpected complications (quality follow-up), 2 undiagnosed-driver cases needing clinical review. Flagging the 5 CHF members for care management escalation—estimated $340K avoidable cost if we can reduce their readmission pattern.
Model the impact of closing our 487 open A1c gaps.
Modeling. Direct quality bonus: estimated +$180K (Star rating tier movement probability: 64%). Downstream avoided cost: reducing HbA1c >9 cohort by this much historically correlates with $220–$380 PMPY reduction for affected members over 18 months = approximately $110K–$190K this contract year. Combined near-term impact: $290K–$370K. Net of outreach and intervention costs (~$45K), net benefit $245K–$325K.