Risk Pools & Shared Savings Module
Provider risk arrangement management including capitation pools, withhold programs, shared savings calculations, and settlement processing.
5
Pages
4
API Endpoints
5
High-Priority Orgs
5
Requirements
Organization Relevance
MCO: High Health Plan: High IPA: High PHO: High ACO: High TPA: Low MSO: Low FQHC: Low
How It Works
Risk pools are configured based on provider contract terms. Capitation payments are calculated from enrollment. Withholds are retained from payments and tracked against quality/cost targets. Shared savings calculations compare actual costs against benchmarks. Settlement processing distributes surplus or recovers deficits at period end.
Requirements
- Provider contract risk terms
- Capitation calculation engine
- Benchmark/target setting
- Settlement calculation and distribution
- Risk corridor management
Target Audience
Provider Contracting, Finance Teams, Actuaries, Network Management
Pages (5)
| Page | Purpose | Key Features |
|---|---|---|
| Risk Pools Dashboard | Overview of all risk pool arrangements with financial status | Pool overview, Financial metrics, Performance tracking, Settlement status |
| Pool Configuration | Configure risk pool parameters, participants, and terms | Pool setup, Participant management, Term configuration, Effective dating |
| Settlements | Process period-end risk pool settlements and distributions | Settlement calculation, Distribution management, Approval workflow, Payment generation |
| Shared Savings | Calculate shared savings/losses against benchmarks | Benchmark comparison, Savings calculation, Quality gates, Distribution rules |
| Withhold Management | Track provider payment withholds and earn-back conditions | Withhold tracking, Earn-back criteria, Performance reporting, Release processing |
API Integrations
Risk pool configuration APICapitation calculation APIShared savings APISettlement processing API
Referenced Resources
CMS ACO Shared Savings ProgramNAIC Risk-Based Capital RequirementsProvider risk arrangement best practices
Expected Results
Transparent risk arrangement management with accurate financial settlements, quality-linked incentives, and aligned provider-payer incentives.