Importance of Reporting Accuracy for ACO Quality Measures

Healthcare reimbursement for Accountable Care Organizations (ACOs) hinges on accurate reporting of quality measures. When Commercial payers use incorrect specifications or outdated data, ACOs can lose thousands in earned incentive payments. This case study reveals how one Virginia ACO recovered significant reimbursement by leveraging precise population health analytics to challenge payer results and demonstrate its true clinical performance.

The Critical Role of Quality Measures in ACO Performance

_{One of the core tenets of accountable care organizations is a focus on quality of care and achieving contracted quality measures for their members. Quality measures serve as benchmarks for assessing the clinical performance of ACOs in delivering high-quality healthcare. These standardized metrics directly impact financial incentives for healthcare providers and determine reimbursement rates from healthcare payers.}

Why Data Accuracy Matters for Healthcare Reimbursement

ACOs must accurately identify and close care gaps within each patient population to achieve optimal quality measures for each performance year. This process requires aggregating clinical and financial healthcare data, often from multiple disparate systems, to perform the appropriate analysis.

Key challenges include:

• Integrating data from multiple electronic health records (EHRs)
• Ensuring compliance with current HEDIS specifications
• Managing variations across different payer contracts
• Maintaining accurate patient attribution

ACOs depend heavily on their population health analytics partner to effectively generate performance results across their provider networks. To optimize quality performance and maximize reimbursement, ACOs must utilize a trustworthy solution with NCQA-certified partners who adhere to current reporting requirements.

Case Study: How Signature Partners Challenged Payer Quality Measures Results

At the end of an annual performance year, payers reward ACOs for achieving performance targets on their quality measures. Signature Partners, an accountable care organization in northern Virginia, received disappointing news from their payer that would cost them significant revenue.

The Problem: Payer Used Outdated HEDIS® Specifications

During their year-end quality measures review, the payer reported that Signature Partners did not meet the quality measures benchmarks necessary to receive financial compensation. This created a major discrepancy between what the ACO knew they had delivered and what the payer was reporting.

The root cause:

• The payer was using outdated HEDIS measures specifications instead of the current version stipulated in their contract. This led to:
• Incorrect members being included in the payer's final measures results
• Missed incentive payments for Signature Partners and their healthcare providers
• Inaccurate assessment of clinical performance

The Solution: Population Health Analytics Data Verification

To address this concern, Signature Partners used Koan Health Datalyst's quality data tracking and reporting capabilities to compare the payer's results with the care they actually delivered. Using the drill-down capabilities of Datalyst, they quickly identified members that met the quality measures but were not included in the payer's calculation.

The investigation revealed:

• Members who met quality measures were excluded from payer calculations
• Payer used custom and outdated HEDIS measures specifications
• Significant disparities between contracted requirements and payer methodology

The Result: Successful Appeal and Proper Reimbursement

Armed with evidence from Datalyst, Signature Partners appealed the payer's results, providing detailed proof that a significant number of members met the contracted quality measures. The comprehensive report demonstrated that their providers had not only met but exceeded the contracted performance metrics.

The outcome was substantial:

• Payer acknowledged Signature Partners met and exceeded the required benchmarks
• "True up" payment issued to correct the underpayment
• Enhanced alignment between ACO, payer, and analytics partner

Utilizing Koan Health's quality measures payer gap comparison tool we were able to quickly identify inappropriate payer gaps in care and submit supplemental data to close those gaps, ensuring our payer quality measures benchmarks were achieved, which resulted in additional savings.

- Signature Partners

How Population Health Analytics Improves ACO Quality Reporting

Koan Health's Datalyst platform empowers ACOs to track and report quality measures performance accurately and efficiently. As commercial payers use different quality measures, the analytics software must accommodate these variations.

Key Features of Effective Quality Measures Tracking

Multi-Standard Support:

• HEDIS measures compliance
• Medicare Shared Savings Program (MSSP) metrics
• Medicare STAR ratings
• Custom quality measures catalogs

Comprehensive Performance Views:

• Enterprise-level reporting
• Program/payer-specific analysis
• Group and physician-level insights
• Individual patient tracking
• Extensive filtering capabilities

The Importance of NCQA Certification

Datalyst's HEDIS quality measures are certified by NCQA, ensuring that results captured in the platform are appropriate and aligned with current HEDIS quality measures specifications. Additionally, Datalyst is NCQA DAV certified, which means ACOs can use the platform to generate data extracts for sending aggregated supplemental data back to payers.

Best Practices for ACO Quality Measures Optimization

Claims Data Aggregation Strategies

The quality measures capability within Datalyst offers multiple approaches for ACOs to view their quality measures gaps and assess performance. For commercial payers, the payer gap comparison capability compares measures and gaps supported by aggregated clinical and financial data with those presented by the payer, highlighting any disparities.

Essential capabilities include:

• Real-time data integration from multiple sources
• Automated gap identification and tracking
• Supplemental data extract generation
• Performance monitoring across multiple payer contracts

Choosing the Right Analytics Partner

Through this process, Signature Partners emphasized the importance of collaborating with a population health analytics partner committed to data accuracy, transparency, and client success. Having an analytics partner whose culture focuses on clinical and financial data integrity provides reassurance that accurate quality measures, performance, and correct compensation for delivered care are reported for each ACO program.

Don't let inaccurate reporting cost your ACO thousands in earned incentive payments. Connect with our experts to identify potential revenue recovery opportunities and ensure your clinical performance is accurately reflected in payer calculations.

About Signature Partners

Signature Partnersis a clinically integrated provider network affiliated with Inova Health System. As a leading non-profit ACO on the East Coast, Signature Partners has been a close partner of Koan Health since 2015, utilizing Datalyst and Koan support to successfully manage cost, utilization, and quality measure performance across multiple payer contracts.