Value-Based Care Attribution Agent

The work it takes off your plate

Value-based contracts fail operationally when attribution is disputed, quality gaps are discovered too late, and total cost of care (TCOC) insights are fragmented across payers. Finance, quality, and care management work from different rosters, causing missed shared-savings opportunities and surprise downside risk. The Value-Based Care Attribution Agent maintains living attribution, tracks quality performance, and surfaces TCOC trends with actionable leaks so VBC teams can manage contracts proactively.

How it works

The agent reconciles payer attribution files with internal panels, monitors quality measure denominators and numerators, calculates TCOC and leakage metrics, and alerts owners when attribution, quality, or cost trajectories threaten contract performance.

1. Step 1: Reconcile Attribution and Panels

   • Ingest payer attribution, prospective/retrospective methodologies, and internal PCP panel assignments
   • Detect joiners, leavers, dual assignments, and disputed members
   • Generate appeal packets for incorrect attribution with visit and claim evidence

   Result: A reconciled attributed membership file with dispute queue and audit trail.

2. Step 2: Track Quality Measure Performance

   • Map members to contract quality measures and STAR/HEDIS-aligned metrics
   • Compute open gaps, predicted year-end rates, and measure-level opportunity ranking
   • Route gap worklists to clinics and care management with measure-specific actions

   Result: Near real-time quality scorecards with prioritized closure opportunities.

3. Step 3: Analyze Total Cost of Care and Leakage

   • Aggregate medical and pharmacy spend PMPM by service category and high-cost claimants
   • Identify out-of-network leakage, site-of-service shifts, and avoidable acute utilization
   • Link cost drivers to care programs and specialty referral patterns

   Result: TCOC insights with actionable leakage and high-cost member flags.

4. Step 4: Publish Contract Intelligence and Alerts

   • Produce contract dashboards for quality, cost, and attribution movement
   • Alert finance and clinical owners when performance crosses risk corridors
   • Support quarterly joint operating committee packs with narrative variance analysis

   Result: Shared VBC intelligence enabling timely interventions before settlement.

Why use it

• Living Attribution. Continuous reconciliation reduces roster disputes.
• Quality Foresight. Predicted rates and gap queues before year-end scrambles.
• TCOC Transparency. PMPM, leakage, and high-cost drivers in one place.
• Contract Alerts. Early warning on downside risk corridors.
• Cross-Team Alignment. Finance, quality, and care management share one source of truth.