A quick practice snapshot to get us started

• Tell me briefly about your practice model, location, and whether you operate as independent, part of a group, or under a larger health system Options: Independent solo or small group, Independent multisite group, Clinically affiliated with hospital/health system, Federated network or management services organization, Other
• How many clinicians and mid-level providers are on site across your locations Options: 1-3, 4-10, 11-25, 26-50, 51+
• Which patient panel sizes and payer mixes best describe your typical primary care site Options: Small panel <2,000, predominantly Medicare, Small panel <2,000, mixed payers, Medium panel 2,000–5,000, mixed payers, Large panel >5,000, commercial heavy, Other
• In a typical month, how many annual wellness visits (AWVs) and chronic-care outreach tasks does a single clinician need to complete Options: Under 50, 50–150, 150–300, 300+
• Do you currently have a target for shared savings participation, downside tolerance, or a threshold that would rule this out Options: Targeting upside only (no downside), Open to limited downside with stop-loss, Willing to accept full downside, No clear target yet, This would rule us out

Where your daily workflows leak value

• When was the last time your practice missed a quality payment or incentive because of data, documentation, or workflow gaps, and what happened
• Walk me through the steps your team takes when a high-risk patient needs outreach from identification to closure
• Which specific part of that flow, for example lab reconciliation, scheduling AWVs, or post-discharge follow-up, consumes the most time or causes the most missed opportunities Options: Patient identification / attribution lists, Care gap lists and recall, Scheduling and patient outreach, In-visit documentation and coding, Post-discharge reconciliation, Other
• Who on your team notices these misses first, and how do they normally escalate them Options: Front desk / scheduling, Clinical MA or nurse, Practice manager, Billing / revenue cycle, Physician or medical director, Other
• Pinpoint a recent patient example where the current workflow failed and explain the downstream impact on revenue, quality score, or patient care

Outcomes that would change the math for you

• What single outcome, expressed in quality measure improvement, savings percent, or AWV lift, would make participation worth the effort for your practice Options: Quality measure priority (e.g., HEDIS/MIPS lift), Net shared savings >= 3% of revenue, Increase AWV completion by 25%+, Reduced hospital readmissions by 10%+, Other
• Describe how a successful year would look operationally, for example changes to staff time, workflows, and patient touchpoints
• If you were to list your top three financial and clinical priorities for the next 12 months, what are they
• List the top three metrics you already track internally that relate to those priorities Options: AWV completion, Chronic disease registries (e.g., diabetes, HTN), ED utilization per 1,000, Total cost per attributed patient, Preventive care measure rates, Other
• How confident are you that your current tools can reliably report those metrics for an external payer or ACO audit Options: Very confident, Somewhat confident, Not confident, Unknown
• If a pilot showed a 5% reduction in total cost of care while holding quality steady, what internal steps or approvals would have to happen for you to sign within two weeks

Who controls the risk and who executes it

• Assuming your practice considered downside risk, where would the biggest financial exposure fall and why
• Name the roles that must approve participation at your practice and the order in which approvals typically happen
• Who would run care management and daily coordination after go-live, and is that a current role or a new hire Options: Existing RN or MA, New embedded care manager hire, Third-party manager contracted, Shared regional care team, Other
• Describe the current onboarding and clinical training cadence for new staff and how much protected time you can allocate for training in a quarter Options: 1-2 hours per clinician per month, Half day sessions quarterly, Full day onboarding per hire, No protected time available, Other
• What single governance, reporting, or accountability gap would cause you to pause joining a shared savings arrangement

The other options on your short list

• Across the alternatives you are considering, which approach feels closest to a safe choice and why
• List the vendors, incumbents, or internal build-options you have evaluated so far
• Under what specific conditions would you decide to stay with your current approach instead of switching to an external ACO platform
• Have any internal leaders proposed solving population health capabilities in-house, and if so who would lead that effort Options: Yes, clinical leadership, Yes, IT/operations, Yes, finance, No internal proposal, Other
• Estimate one-time and annual costs you expect if you were to build these capabilities internally, even as rough bands Options: <$50k one-time / <$25k annual, $50k–$150k one-time / $25k–$100k annual, $150k+ one-time / $100k+ annual, Unsure
• Point to the alternative that would make you end this evaluation today and tell us what it offers that matters most

Concrete readiness and integration constraints

• Imagine your external data feed failed for two weeks, identify what breaks first and who on your team would raise the alarm
• Enumerate the EHR systems, versions, and whether your practice controls the integration endpoints for each
• Identify the person or role who owns payer IDs, enrollment, and contracting relationships for your practice
• Do you have internal IT or third-party integration support that can manage secure feeds, FHIR/API connections, or HL7 interfaces Options: Internal IT team available part time, Internal dedicated resource, Third-party integrator under contract, No integration capacity currently
• Rate the accessibility and cleanliness of your claims, encounters, and problem list data today Options: Ready for integration with minor cleanup, Significant gaps but usable, Fragmented and not ready, Unknown / need assessment
• Name any legal, compliance, or payer approvals that must be obtained before a pilot can start and estimate typical lead times
• Identify the single technical or contractual blocker that would prevent deployment from starting on your preferred timeline

If the pilot works, what accelerates or stops a signature

• Assuming the pilot meets the agreed success metrics, what internal change or decision would be required for you to execute a contract within 30 days
• Select the one success metric that will be most decisive for your leadership, quality measures, cost reduction, or AWV completion Options: Primary quality measure lift, Net cost reduction percentage, AWV completion rate, Reduced ED visits or readmissions, Other
• When do your next budget reviews, board meetings, or partner approval cycles occur that could affect contract timing Options: Within 30 days, 30–60 days, 60–90 days, 90+ days, No fixed cycle
• State your internal target window for go-live after contract execution if approvals are completed Options: 30 days, 60 days, 90 days, 120+ days, Unsure
• Point to the person or decision that can block the agreement after leadership review and explain what evidence they will need to sign

• Solution Experience — Care Model & Platform Walkthrough

• Quick orientation, what happens between signing and go-live
• You confirm the demonstrated analytics and care workflow eliminate the specific gaps and rework you described in Discovery.
• Provide a de-identified sample patient panel (500-1,000 attributed patients) and your current EHR name and version.
• You accept the sample financial example as a realistic path to shared savings with explicit downside controls.
• Confirm the current state and its cost to your practice
• Seller to run a tailored 12-month financial model using the provided panel and deliver the model before the follow-up session.
• Proof — patient identification and gap closure using your scenario
• Seller to execute a short trial feed on a de-identified subset and deliver a care-gap report that mirrors the live walkthrough within two weeks.
• You agree on the evidence and integration steps remaining before a contracting decision.
• Proof — care coordination workflow in your clinic context
• Identify your internal decision criteria and timeline for participation, and share with the seller before the next meeting.
• Proof — financial flow and downside protection example
• Validate the future state
• Agree remaining evidence and next steps

• Solution Experience — Care Model & Platform Walkthrough
• Solution Experience Deck
• Solution Brief

• meeting
• slides
• document

• EHR Data Integration and Daily Feed
• Risk Stratification and Patient Registry Build
• Deploy Embedded Care Managers
• Care Coordination Workflow Implementation
• Chronic Disease Management Programs
• Annual Wellness Visit Support and Coding
• Quality Measure Abstraction and Reporting
• Claims Processing, Attribution, and Reconciliation
• Shared Savings Calculation and Distribution
• Payer Contracting and Risk Arrangement Management
• Regulatory Compliance and Audit Support
• Performance Dashboards and Monthly Reporting
• Practice Staff Training and Change Management
• Patient Engagement and Outreach Campaigns

EHR Data Integration and Daily Feed

• Which EHR exchange formats can your current system produce for a daily clinical feed (e.g., Consolidated CDA, FHIR Patient/Encounter, HL7 v2 ADT or ORU)? Options: Consolidated CDA (CCDA), FHIR (Patient, Encounter, Observation), HL7 v2 ADT/ORM/ORU, Flat-file export (CSV), Other / Unsure
• Who on your IT team can provide API credentials and firewall/IP allowlist approvals for daily feeds?
• How many attributed patients should be present in the initial daily feed (estimated count)? Options: Less than 500, 500-2,000, 2,001-10,000, More than 10,000
• How will you verify daily feed completeness and timeliness: define the acceptance criteria and monitoring threshold for record arrival (example: >=95% of encounters for attributed patients arrive within 24 hours)? Options: We will accept proposed threshold, We need to negotiate threshold, We cannot meet daily timeliness
• When can you provide a test EHR export for initial mapping and what daily window do clinicians expect (e.g., overnight 02:00-06:00)? Options: Overnight (00:00-06:00), Business hours (08:00-18:00), Custom window (provide details), Unsure
• Which patient identifiers must be preserved in the feed to match claims and attribution (for example: medical record number, date of birth, Medicare Beneficiary Identifier, payer member ID)?

Risk Stratification and Patient Registry Build

• Which sources should contribute to the registry build for risk scores: your EHR problem list, problem list crosswalked to ICD codes, historical claims, or lab/medication data? Options: EHR problem list, Historical professional/medical claims, Pharmacy fills, Labs and vitals, Other
• Who will own ongoing reconciliation between claims-based risk and EHR problem-list HCCs on your side?
• How many months of claims or encounter history should we include for baseline risk modeling (options reflect data availability)? Options: 3 months, 6 months, 12 months, 24+ months
• How will you validate the registry build accuracy: state the measurable acceptance threshold for patient-level match and HCC capture (example: registry matches claims attribution >=90% and HCC capture within +/-2%)? Options: Accept proposed threshold, Require different threshold (specify), Undecided
• Identify the clinical flags or cohorts you want prioritized for care management (examples: uncontrolled diabetes with A1c >9%, multiple admissions in 6 months, complex polypharmacy).
• Which risk scoring method do you prefer for stratification (select available inputs you can provide)? Options: Claims-based risk score (e.g., CMS-HCC inputs), EHR-based clinical risk algorithm, Hybrid claims + EHR model, No preference / recommend

Deploy Embedded Care Managers

• How many full-time equivalent embedded care managers does your practice need on go-live? Options: 0.5 FTE, 1.0 FTE, 1.5 FTE, 2.0+ FTE
• Where will embedded care managers be physically located (options to capture on-site, hybrid, or virtual)? Options: Fully on-site, Hybrid (split on-site/remote), Fully remote
• Who will supervise embedded care managers in your organization and what is the escalation path for complex clinical issues?
• Which clinical responsibilities should embedded care managers perform at launch (for example: transitional care calls, medication reconciliation, high-risk outreach, AWV scheduling)? Options: Transitional care outreach, Medication reconciliation, High-risk patient outreach, AWV scheduling and prep, Other
• How will success of embedded care managers be measured in the first 90 days (examples: number of high-risk patients engaged, percent with care plan documented)?
• Do you have space, badge access, and clinical EHR login licenses available for embedded staff at go-live? Options: Yes, all available, Partial (need licenses or space), No — will require remote deployment

Care Coordination Workflow Implementation

• Which care coordination workflows must be implemented first: transitions of care, referrals, post-discharge follow-up, or chronic care huddles? Options: Transitions of care, Referral management, Post-discharge follow-up, Chronic care huddles, All of the above
• Who on your clinical staff currently owns referral routing and follow-up confirmation?
• How many referral partners require an inter-organizational workflow (e.g., hospital discharge teams, skilled nursing facilities)? Options: None, 1-3, 4-10, More than 10
• Which EHR workflow artifacts must be populated when care managers open a case (for example: encounter type, problem list entry, care plan template, visit task)? Options: Encounter note template, Problem list update, Care plan template, Task assignment
• Describe the notification channels you require for care team handoffs (examples: EHR in-basket message, secure chat, daily huddle report).
• Will your practice require custom order sets or documentation templates to support the coordination workflows? Options: Yes — custom order sets, Yes — custom documentation templates, No — use standard templates, Unsure

Chronic Disease Management Programs

• Which chronic conditions should be in scope for disease management at launch (examples: diabetes with A1c >8, CHF with recent admission, COPD with oxygen therapy)? Options: Diabetes, Congestive heart failure (CHF), Chronic obstructive pulmonary disease (COPD), Hypertension, Other
• Who on your clinical team will be the clinical lead for each disease program and who will approve clinical protocols?
• How often should program members receive outreach cadence (e.g., weekly calls, monthly monitoring, quarterly check-ins)? Options: Weekly, Bi-weekly, Monthly, Quarterly
• Which remote monitoring devices or biosensor data do you plan to incorporate into disease management (examples: home BP cuffs, glucometers, weight scales)? Options: Blood pressure cuff, Glucometer, Weight scale, Pulse oximeter, None
• Identify the clinical thresholds that should trigger escalation to a clinician (examples: A1c >9, systolic BP >160, weight gain >5 lbs in 7 days).
• Do you require program-level patient education materials and care plan templates tailored to your patient population? Options: Yes — materials and templates, No — use generic materials, Unsure

Annual Wellness Visit Support and Coding

• Which AWV workflow elements do you need support for: pre-visit outreach, preventive service checklist, Medicare AWV documentation, or billing/coding validation? Options: Pre-visit outreach, Preventive checklist, AWV documentation template, Coding and billing validation
• Who will be responsible for scheduling and preparing patients for AWVs within your practice?
• How many AWVs per month do you expect to complete after launch? Options: 0-10, 11-25, 26-50, 50+
• Which AWV billing codes should be validated in your billing system (enter known CPT/G-codes or indicate vendor will supply list)? Options: We will supply codes, We want the team to recommend codes, Unsure
• When do you want AWV outreach to start relative to go-live (examples: 30 days before, at go-live, 60 days after)? Options: 30 days before go-live, At go-live, 30-60 days after go-live, 60+ days after go-live
• Do you require documentation templates that auto-populate medication lists, preventive screens, and care plan elements for AWVs? Options: Yes, No, Partial — prefer recommendations

Quality Measure Abstraction and Reporting

• Which quality measure sets do you need reported: Medicare Shared Savings Program measures, Medicare Advantage measure sets, or commercial contract measures? Options: Medicare Shared Savings Program, Medicare Advantage, Commercial payer measures, Other / custom
• Who will provide denominators and any manual chart abstraction evidence if CMS or a payer requires chart-level confirmation?
• How often do you require measure refreshes and reports (monthly, quarterly, annually)? Options: Monthly, Quarterly, Annually, On request
• How will you verify reported measure compliance and attestation readiness: define the evidence threshold and acceptance criteria for each measure (example: source documentation for 100% of sampled claims)? Options: Accept proposed evidence threshold, Require different sampling/threshold, Undecided
• Which EHR chart zones should abstractors reference for measure evidence (examples: problem list, medication list, preventive care flowsheet, lab results)? Options: Problem list, Medication list, Preventive flowsheet, Lab results, Visit notes
• Do you need automated numerator/denominator calculations in the registry or manual abstraction by certified abstractors? Options: Automated calculations, Manual abstraction, Hybrid approach

Claims Processing, Attribution, and Reconciliation

• Which payer claim feeds can you provide for reconciliation (options: Medicare FFS claims, Medicare Advantage encounter data, commercial professional claims)? Options: Medicare FFS claims, Medicare Advantage encounter data, Commercial professional claims, None available
• Who on your billing team will coordinate remittance and ERA (electronic remittance advice) ingestion for reconciliation?
• How frequently do you want attribution and reconciliation runs (daily, weekly, monthly)? Options: Daily, Weekly, Monthly, Quarterly
• Which attribution rule set should we use for initial reconciliation (examples: plurality of primary care E&M visits, historical payer attribution file)? Options: Plurality of primary care visits, Payer-provided attribution file, Hybrid ruleset, Undecided
• Identify the tolerance for reconciliation variance between claims and EHR attribution that you will accept before escalation (example: <3% variance in attributed lives). Options: <1%, <3%, <5%, Other
• Do you have a preference for automated claim matching keys (for example: member ID + service date + provider NPI) or manual review? Options: Automated matching keys, Manual review, Hybrid

Shared Savings Calculation and Distribution

• Which cost and utilization baselines should we use for shared savings modeling (examples: rolling 12-month claims baseline, payer-specific historical baseline)? Options: Rolling 12-month claims baseline, Payer-specific historical baseline, Custom baseline (specify)
• Who on your finance team will approve the distribution schedule and reporting cadence for shared savings?
• How often should shared savings be calculated and distributed (quarterly, biannually, annually)? Options: Quarterly, Biannually, Annually
• Which allocation drivers are required for distribution (examples: panel size, performance on quality measures, risk-adjusted savings)? Options: Panel size, Quality performance, Risk-adjusted savings, Other
• Indicate any fixed contractual constraints on distribution (for example: minimum reserve retained by the ACO or holdback percentage). Options: No constraints, Reserve required (specify), Holdback percentage (specify)
• Do you require an audit trail and exportable ledger for every shared-savings calculation and payment? Options: Yes, No, Partial — summary only

Payer Contracting and Risk Arrangement Management

• Which payer contract types are in scope for this deployment: Medicare Shared Savings Program, Medicare Advantage, commercial gainshare or downside-risk arrangements? Options: Medicare Shared Savings Program, Medicare Advantage, Commercial value-based contracts, Downside risk arrangements
• Who will be the authorized signatory for payer contracting and who will coordinate payer data access on your side?
• How should contract-level performance attribution be rolled up to practice-level reporting (by TIN, by clinic location, by individual NPI)? Options: By TIN, By clinic location, By NPI, Custom aggregation
• Which contractual risk corridors or floors must the scope model respect when presenting financial projections?
• Will you require assistance with payer data use agreements and Business Associate Agreement (BAA) review? Options: Yes — review and redline, No — we handle BAAs, Partial — initial review only
• Specify any payer-specific requirements for patient notification or opt-out workflows mandated by contract.

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Subscription Order Form
• Data Use & Sharing Agreement
• HIPAA Business Associate Addendum (BAA)
• Financial Risk Sharing Agreement
• Payer Contracting & Agent Authorization
• Provider Participation Agreement
• Fee Schedule & Payment Terms
• Approvals & Signoff Matrix

• Go-live Health Check (weeks 1-4)
• First Outcome Measurement (weeks 4-10)
• Acceptance Gate Review (around day 90)
• Quarterly Success Review (ongoing)

• Circulate the quarterly action plan and schedule the next Quarterly Success Review.
• Publish the go-live issue log with owners and target resolution dates within 48 hours.
• Re-confirm success criteria and owners
• Produce a documented pass/fail decision for each numeric acceptance criterion recorded in the Solution Scope.
• For any non-passing criteria, agree a remediation plan with concrete dates and validation steps.
• Publish the acceptance decision and next steps within 48 hours of the meeting.
• Publish the formal acceptance record showing pass/fail per criterion and any conditional items within 48 hours.
• For failed or conditional criteria, produce a remediation schedule with validation tests and target dates.
• If all criteria pass, transition the tracked items to the Ongoing Quarterly Success Review cadence and update the dashboard access.
• Performance trends and variance analysis
• Confirm whether the ACO quality measure composite and AWV completion rate remain on track against Solution Scope targets.
• Reduce the high-priority issue backlog and assign clear resolution timelines for remaining blockers.
• Prioritize enhancement requests for the next quarter and document the deliverables and timelines.
• Update and publish the issue backlog with status and target resolution dates within 5 business days.
• Publish the prioritized enhancement request list and the planned delivery quarter within 10 business days.
• Set the date and prerequisites for the First Outcome Measurement meeting.
• Confirm feeds, attribution, and access are functioning so first outcome measurement will be valid.
• Produce an agreed open-issue list with owners and target resolution dates.
• Enable read-only access to the outcome dashboard for named buyer users and confirm access within 3 business days.
• Schedule the First Outcome Measurement meeting once all critical blockers are cleared or mitigated.
• Present first-period outcome data
• Determine whether AWV completion rate and risk-adjusted total cost of care per attributed beneficiary are trending toward the Solution Scope targets.
• Agree a prioritized remediation plan with deadlines to close identified gaps before the acceptance gate.
• Confirm the acceptance gate date and the data package required for that meeting.
• Produce a detailed metric drill-down report for AWV completion rate and risk-adjusted total cost per attributed beneficiary within 10 business days.
• Create and publish a remediation plan with discrete tasks and target dates to address each identified root cause.
• Deliver the dataset and data lineage notes that will be used in the Acceptance Gate meeting at least 7 calendar days before that meeting.
• Restate acceptance criteria and numeric targets
• Present outcome data against each criterion
• Deployment and data feed validation
• Persistent issues and blocker burn-down
• Diagnose root causes for any gaps
• Enhancement requests and prioritization
• Early adoption and usage signals
• Document pass or fail per criterion and record decision
• Agree corrective actions and owners
• Agree remediation or realization tracking plan
• Open issues and blockers
• Confirm readiness and timeline to acceptance gate
• Agree quarterly action plan and next checkpoints
• Immediate remediation actions