Description

A focused course, tailored for you

The At-Risk Payer Contract Operator Playbook

How an operator structures at-risk payer contracts, runs the truing-up, and keeps the health IT feeds honest across the year.

The actuary's PMPM reconciliation memo lands and the medical loss ratio gap needs an explanation paragraph the executive committee will accept.

$199 one-time

Tailored to your situation. Access within 24 hours. 30-day money-back.

Includes a hand-built implementation playbook delivered alongside course access, generated for your specific situation.

Why this course

Value-based healthcare executives who own at-risk payer contracts live in a recurring loop. The attribution file arrives with members assigned to closed clinics and ED utilisation that does not reconcile to claims. The actuary models the trend, the finance team challenges the variance, and the explanation paragraph is yours to write. Chart-review submissions lag the risk-score cycle by months, the health IT integrations break quietly between the claims feed, the ADT stream and the eligibility roster, and the truing-up meeting with the payer is on the calendar regardless. The job is not to model the contract. The job is to operate it across the year so the truing-up holds up and the next contract negotiation starts from a defensible baseline.

What you walk away with

Read an at-risk payer contract and identify the three clauses that will drive the year-end truing-up before the first month closes.
Run an attribution audit against the payer's roster, file a defensible dispute, and track resolution through the quarterly cycle.
Build a chart-review and HCC-recapture workflow that closes the gap between the clinical record and the risk score the payer accepted.
Specify the health IT integrations (claims, ADT, eligibility, pharmacy) the actuary needs to model the trend without manual reconciliation.
Write the executive variance narrative the finance leader forwards to the board without asking a follow-up question.

The 12 modules

Module 1. At-risk contract structures and where each one breaks

PMPM, shared-savings, full-risk and capitation are not interchangeable. This module walks the operating mechanics of each structure, the clauses that decide who carries the loss in a bad year, and the early-warning signals that tell you which structure is failing in month four rather than month eleven. Includes a contract-clause walkthrough you can run against your live agreement.

Module 2. The attribution roster and how to dispute it

Attribution decides who counts against the contract. Members assigned to closed clinics, members who never visited a contracted provider, and members assigned twice across overlapping rosters all distort the medical loss ratio. This module covers the attribution methodology common to commercial and Medicare Advantage payers, the audit you run against the roster monthly, and the dispute-letter template that survives a payer pushback.

Module 3. Chart review and HCC recapture across the contract year

Risk scores lag clinical reality by two cycles unless chart review and HCC recapture run on a deliberate workflow. This module covers the conditions that recapture each year, the documentation the auditor will accept, the prospective versus retrospective review tradeoff, and the cadence that closes the score gap before the truing-up meeting rather than after.

Module 4. The claims feed and the actuary's reconciliation model

The actuary cannot model what the claims feed does not show. This module specifies the claims data the actuary needs (paid date, service date, member ID, provider ID, diagnosis, procedure, paid amount, allowed amount), the reconciliation cadence that catches a feed break in week one, and the variance flags that distinguish a real trend from a data-quality artefact.

Module 5. ADT, eligibility and pharmacy as second-order signals

Admission/discharge/transfer messages, eligibility files and pharmacy claims arrive at different cadences and reconcile against different identifiers. This module covers the integration patterns that keep ADT current enough to support care management, the eligibility cadence that catches retroactive disenrollment before it distorts PMPM, and the pharmacy claims feed that supports chronic-condition risk-score work.

Module 6. Care management and the at-risk operating leverage

Care management is the operating lever that moves the medical loss ratio. This module covers the stratification logic that identifies the members who drive 80 percent of cost, the engagement cadence that produces measurable utilisation change, the documentation that flows back into the risk score, and the staffing model that holds across a growing attributed panel.

Module 7. The quarterly truing-up cycle with the payer

The truing-up is the quarterly meeting where the payer and the operator reconcile attribution, claims, risk scores and PMPM against the contract. This module walks the meeting agenda, the artefacts you bring (attribution audit, variance memo, chart-review log, integration status), and the negotiation moves that recover months the data-quality issues would otherwise concede.

Module 8. Medical loss ratio variance and the executive narrative

A medical loss ratio variance becomes a board paragraph only when somebody writes the narrative. This module covers the variance decomposition (trend versus attribution versus risk score versus utilisation), the language that distinguishes a one-time event from a structural shift, and the paragraph the finance leader forwards to the board without a follow-up question.

Module 9. Provider network economics under at-risk

Under fee-for-service the network is a cost. Under at-risk the network is a portfolio. This module covers the unit economics of in-network versus out-of-network utilisation, the steerage moves that hold without breaking access standards, the high-cost specialty referral patterns that drive the worst variances, and the network-contracting moves that protect the at-risk margin.

Module 10. Quality measures and the bonus pool reconciliation

Most at-risk contracts carry a quality gate that decides whether the shared savings or the bonus pool flows. This module covers the HEDIS and CMS Star measure set the contract references, the data submission cadence, the supplemental data feed that closes the gap between the claims-based measure and the clinical reality, and the reconciliation that holds when the payer rescores at year end.

Module 11. The next contract negotiation and what defensible baseline means

The next contract is negotiated against the data you produced this year. This module covers the baseline metrics the payer will reference (medical loss ratio, attribution stability, risk-score trend, quality performance), the case you build for a more favourable PMPM or a higher shared-savings split, and the contract-language asks that protect operating leverage in the next term.

Module 12. The annual operating rhythm across multiple at-risk contracts

Running one at-risk contract is operational. Running a portfolio of at-risk contracts is a planning discipline. This module covers the annual rhythm that holds across contracts of different structures and renewal dates, the shared infrastructure that supports them (claims feed, attribution audit, chart-review workflow, executive narrative cadence), and the staffing model that scales without losing the per-contract truing-up rigour.

How this addresses your situation

Specific modules that map to what you said you are dealing with.

The actuary delivers the PMPM reconciliation memo and the medical loss ratio gap needs an executive explanation by the finance committee meeting next week.

The attribution file arrives with members assigned to closed clinics and the dispute letter has to go back to the payer this cycle, not the next one.

The truing-up meeting with the payer is on the calendar and the chart-review log, attribution audit and integration status all have to line up.

The next at-risk contract negotiation starts and the baseline data the payer will reference comes from the year you just operated.

What you get with this course

Twelve written modules in the Art of Service learning environment, each with worked examples drawn from at-risk payer contract operations.
Downloadable templates: the attribution dispute letter, the variance decomposition memo, the chart-review and HCC-recapture tracker, the truing-up meeting brief, and the executive narrative paragraph.
The hand-built implementation playbook, written against an at-risk payer contract of your description and delivered alongside course access.
30-day money-back guarantee.

What you will have in hand by Day 1, Week 1, Month 1

Within 24 hours: account in the Art of Service learning environment is provisioned and the hand-built implementation playbook is delivered alongside it.

Weeks 1 to 3: modules 1 through 4. Contract structure, attribution audit, chart-review workflow, and the actuary's claims feed.

Weeks 4 to 6: modules 5 through 8. ADT and eligibility integrations, care management, quarterly truing-up, and the executive variance narrative.

Weeks 7 to 9: modules 9 through 12. Network economics, quality reconciliation, next-contract negotiation, and the annual operating rhythm across the portfolio.

Before and after

Before

The PMPM reconciliation memo lands and the medical loss ratio variance gets explained in a meeting nobody is comfortable in. The attribution roster is queried in spreadsheets, the chart-review backlog grows quietly, and the truing-up meeting with the payer concedes ground because the data did not line up in time.

After

The reconciliation memo lands and the variance is decomposed by trend, attribution, risk score and utilisation in a single paragraph the finance leader forwards to the board. The attribution audit runs monthly, the chart-review workflow closes the score gap before the truing-up, and the next contract negotiation opens from a defensible baseline.

What happens if you do not address this

The variance keeps getting explained in meetings rather than in a defensible memo. The attribution file keeps eroding the PMPM and the chart-review backlog keeps the risk score below the clinical reality. The payer reads that pattern and the next contract terms tighten rather than loosen, and the operating leverage you should have carried into next year quietly transfers across the table.

Who it is for

A value-based healthcare executive with operating responsibility for at-risk payer contracts. Background spans payer-side negotiation, provider-side operations, and the health IT stack that has to feed the actuary clean. Comfortable across PMPM, shared-savings and full-risk structures, comfortable challenging an attribution roster, and accountable to a finance leader who wants the variance explained in a paragraph the board will read without a second meeting.

Who this is NOT for. Clinicians who only see at-risk contracts through the quality-measure end of the workflow. Actuaries who model the trend but do not own the operational reconciliation. Health IT integrators who deliver feeds but do not sit in the truing-up meeting. The course assumes you own the contract end to end, from the negotiation memo through the year-end reconciliation.

How it arrives

Text-based course in the Art of Service learning environment, plus downloadable templates and worked examples for every module, plus the hand-built implementation playbook delivered alongside course access.

Time investment. Plan on 8 to 10 hours across the twelve modules, spread over six to nine weeks. The downloadable templates and the implementation playbook are designed to drop into your current truing-up cycle, so the time investment pays back inside one quarterly reconciliation.

Why $199 is the right number

The actuarial firm will model the trend but will not run the attribution audit or write the executive narrative. The consultancy will run a one-time at-risk readiness assessment but will not stay through the truing-up. The free webinars from the major payer associations cover the contract structures but stop short of the operating workflow. This course is the operator's playbook for running an at-risk contract across the year, written for someone who already understands the math and needs the operating rhythm.

FAQ

Is this written for the payer side or the provider side?

The operator side. Whether you sit at a payer, a provider organisation, an enabler or a management services organisation, the at-risk contract is the same artefact and the truing-up is the same meeting. The course is written for whoever owns the contract end to end.

Does it cover Medicare Advantage, commercial value-based, and direct contracting?

Yes. The contract structures differ in clause language and risk-score methodology, but the operating workflow (attribution, chart review, claims feed, truing-up) holds across all three. Module 1 walks the structural differences, the rest of the modules cover the workflow that applies regardless.

What's the hand-built implementation playbook?

When you enrol, the playbook is written against an at-risk payer contract of your description, naming the contract structure, the payer cadence, the integration stack and the team you operate with. It is delivered alongside course access, not after.

How is the course delivered?

Written modules in the Art of Service learning environment with downloadable templates and worked examples. The implementation playbook arrives as a written document alongside course access.

30-day money-back guarantee. If after a week of working through the materials this is not what you needed, reply to the receipt email and a full refund is processed. No questions, no forms.

Within 24 hours your account in the learning environment is provisioned and the tailored implementation playbook is delivered alongside it.