How ACOs Can Benefit from New Provider Access Requirements

Over the past decade, Accountable Care Organizations (ACOs) have proven to offer a reliable, cost effective model for delivering care to patients. ACOs participating in the Medicare Shared Savings Program (MSSP), ACO Reach, and other models have saved billions of dollars for Medicare, and have been on the leading edge of developing care management programs.

In order to recognize these savings, ACOs work tirelessly to implement population health analytics, identify high-risk patients or those with complex health needs, and enroll those patients in care plans that can improve outcomes while simultaneously preventing more drastic and costly care down the line. 

Historically, aggregating and making sense of the data required to identify those patients within an ACO’s attributed member population has been a time-consuming and difficult process. As ever in healthcare, data is fragmented, siloed, and not easily computable. 

New regulations from CMS offer an opportunity to improve an ACO’s ability to easily access and utilize the data they need to inform care management programs, deliver better care to patients, and reduce costs across the healthcare system. 

Timely data helps identify patients who are overdue for services like cancer screenings or HbA1c tests. For example, if a diabetic patient visits the emergency department, timely data feeds can alert the primary care team, prompting a follow-up to ensure appropriate management and care continuity. This rapid response can reduce the likelihood of future acute events and improve quality scores tied to chronic condition management.

Provider Access APIs Provide Timely Claims Data to ACOs

Last year, CMS published CMS-0057, formally titled the CMS Interoperability and Prior Authorization final rule. Not called out in the title, but perhaps even more exciting, is a requirement for Payer-to-Provider APIs – also known as Provider Access APIs – to be implemented and live by January 1, 2027. While 2027 is still a ways away, 1upHealth will be bringing the APIs live for our Payer customers later this year. 

By integrating payer data, ACOs can identify high-risk patients more accurately and earlier, enabling targeted patient engagement and resource allocation. For example, timely claims feeds can reveal frequent ED visits or hospitalizations, prompting care managers to engage those patients for intervention. 

Additionally, payer data can provide insight into medication adherence, gaps in care (missed diagnostic testing, lack of preventative visits, etc.), and other insights that can be used to improve outcomes and reduce the total cost of care.

Payer data also supports accurate risk adjustment and benchmarking, which are critical to financial success under value-based contracts. Overall, collaboration with payers to access timely, structured data can enable ACOs to build more proactive, effective, and patient-centered care management programs, ultimately leading to better health outcomes and reduced healthcare costs. 

Financial success under value-based arrangements hinges on accurately forecasting and managing shared savings, cost benchmarks, and risk adjustment scores. Delays in data can lead to missed opportunities for coding accuracy, revenue optimization, and early intervention in cost-driving trends. For example, timely claims data can highlight when patients are receiving out-of-network care or duplicative services, issues which can drive up costs and erode margins. Equipped with that information, ACOs can engage providers and patients in corrective action before these behaviors become systemic.

Partner with Us on Payer-to-Provider Data Exchange

We’re excited to power improved patient care through Payer-to-Provider data exchange. We’re actively seeking to partner with forward-thinking ACOs to pilot this new technology. If you’re interested in learning more, or in being an early participant in a data exchange model like this, please reach out.