Medicare ACOs

HEX ACO, built from the ground up to support Medicare ACOs, is being used by ACOs to obtain timely and actionable insights that the ACO leadership depends on every day to drive real performance improvement in how they care for patients and effectively manage resources. For CMS ACOs that are embarking on shared savings managed care models, Hexplora provides a comprehensive overview of their population health, cost, and utilization trends at the ACO level or individual level.

ACOs will succeed or fail based upon their ability to understand and leverage the patient-level data that CMS provides. Transforming this raw data into meaningful insights is among the most challenging and important tasks an ACO has. With Hexplora, ACOs can efficiently track their assigned population each quarter, identify patient and physician outliers, track quality metrics, drill down on specific disease states, perform ROI analyses, and develop targeted interventions.

HEX ACO module supports the following ACO operational processes:

  • Provider Engagement
  • PQRS Quality Reporting
  • Member Tracking
  • Shared Savings Forecasting

Provider Engagement:

ACOs are responsible for facilitating coordination and cooperation among providers to improve the quality of care and reduce unnecessary costs. Hexplora empowers the ACOs through Provider Engagement. PCPs rarely have visibility into the overall healthcare cost for their assigned members. When individual physicians are able to see overall cost and utilization metrics along with a report of their own performance compared to national benchmarks, including, hospitalization rates, re-admission rates, LOS, ER visits, and granular cost data, it is a truly eye-opening experience. All Hexplora Analytics and Reports are available at both the ACO population level and the individual Physician level. Individual physicians with access to these reports are able to manage care for their assigned members and reduce the overall cost. ACO management can use the Provider Performance Reports to identify physicians that are not meeting performance measures and individually engage the physicians in implement provider specific intervention strategies.

PQRS Quality Reporting:

CMS measures quality of care using nationally recognized measures in four key domains. Data collection of quality measures from individual physicians cannot be a completely automated process for most ACOs even if all their physicians are on a common EMR platform. Hexplora includes a web-based application that provides a guided solution for individual physicians for reporting Quality Measures. Our PQRS solution is an end-to-end solution for collecting data from the individual physicians, validating and aggregating the collected data, and Reporting the aggregated ACO level quality measures to CMS.

Member Tracking:

CMS Member Assignment is a multi-step process that uses quarterly Prospective Member Assignments followed by year-end reconciliation that generates the final Retrospective Member Assignment. ACOs are responsible for obtaining and managing patient Consent for data sharing for all their membership. CMS does not share patient demographics and overall claims data with the ACO without patient Consent. Accurate member tracking is essential to maximize availability of data from CMS and for effective population level data analysis for ACOs. Hexplora provides comprehensive support for tracking prospective enrollments, terminations, and patient consent.

Shared Savings Forecasting:

CMS uses complex algorithms that use a combination of Member disease conditions (HCCs) and demographics to calculate Shared Savings for an ACO. Hexplora Shared Savings Forecasting enables ACOs to monitor their expenditure trends in relation to national benchmarks, forecast savings, and implement intervention strategies to meet their performance and savings targets.


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