Payer Performance Tracking
Guides for using PIN's Command Center to track value-based performance, manage STAR and HEDIS programs, model shared savings, streamline prior authorisation, monitor population health, and analyse claims data.
Value-Based Performance
Track quality and cost performance across VBP contracts
PIN's Value-Based Performance dashboard gives your organisation a real-time view of performance across all active VBP contracts — quality scores, cost benchmarks, utilisation trends, and incentive attainment — consolidated from your registry data and linked claims feeds.
Quality Score
87.4
▲ 3.2 pts YTD
Cost Index
0.94
▼ 0.06 vs benchmark
Incentive Earned
$1.2M
▲ 18% vs prior year
Contracts Active
6
Across 4 payers
1
Navigate to Command Center → Payer Performance → VBP Dashboard
The VBP Dashboard is the home screen for all payer performance modules. It shows a summary tile for each active contract and your composite performance score across all programmes.
2
Register a VBP contract
Click + Add Contract and enter the contract details — payer name, programme type (MSSP, Medicare Advantage, commercial ACO, bundled payment, etc.), performance period dates, and the quality and cost thresholds defined in your contract. PIN uses these thresholds to calculate your real-time attainment percentage.
3
Map quality measures to the contract
For each contract, select the quality measures that determine your performance score. PIN maps these to the relevant data fields in the registry (e.g. pain reduction thresholds for pain medicine-specific VBP measures, medication adherence for opioid management programmes). Unmapped measures display a data-gap warning.
4
Monitor performance against thresholds
The VBP dashboard refreshes nightly. Each measure shows current performance, the contract threshold, the gap to target, and a trajectory indicator. Measures in the red zone (below threshold) are surfaced in the Priority Actions panel with the estimated patient-level interventions needed to close the gap before the measurement period closes.
5
Run an incentive projection
Click Project Incentive on any contract to see a modelled estimate of your year-end incentive payment based on current trajectory. Adjust the performance assumption sliders to model "what-if" scenarios — useful for planning care management resource allocation mid-year.
Connect your claims feed VBP cost metrics require a claims data connection. Link your payer's claims feed under Admin → Integrations → Claims Feed to populate cost index and utilisation measures. Without claims data, only quality measures derived from the registry will be available.
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STAR Improvement
Track and improve Medicare Advantage STAR ratings
PIN's STAR Improvement module tracks CMS Medicare Advantage STAR rating measures relevant to pain medicine — including medication management, chronic disease control, and patient experience — and surfaces actionable gaps at the patient level.
STAR Summary
Current estimated STAR rating across all tracked Part C and Part D domains, with projected year-end rating based on current trajectory. Ratings displayed as half-star increments from 1.0 to 5.0.
Measure Drilldown
Expand any measure to see patient-level performance, compliant vs. non-compliant counts, and the interventions needed to move patients from non-compliant to compliant status.
⚡ Quick Wins Panel
Measures where small patient-count improvements would shift the overall STAR rating — ranked by estimated impact per unit effort. Prioritise these for care management outreach.
CMS Deadline Tracker
Countdown timers to measurement period close dates for each STAR measure. Measures with fewer than 60 days remaining are flagged in amber; fewer than 30 days in red.
1
Open Payer Performance → STAR Ratings
Select your Medicare Advantage contract from the contract selector. If this is your first time, register the contract under VBP Dashboard → + Add Contract and select Medicare Advantage as the programme type.
2
Review the measure-level breakdown
Each STAR measure shows its current rate, the threshold for each star tier, and your gap. Click View Patients on any measure to see the list of non-compliant patients with the specific care gap that needs closing — for example, patients on long-term opioid therapy without an annual risk reassessment on file.
3
Create a STAR improvement workplan
Click Build Workplan to generate a prioritised outreach list. Assign patients to care managers, set outreach deadlines, and track completion. As patients receive the required intervention and it is recorded in the registry, their compliance status updates automatically and the STAR rate refreshes.
Pain-specific STAR measures PIN tracks several measures particularly relevant to pain medicine practices: medication adherence for patients on scheduled analgesics, appropriate monitoring for long-term opioid use, and chronic pain patient experience scores derived from CAHPS survey proxies in the registry.
HEDIS Measures
Track, close, and submit HEDIS quality measure data
PIN tracks NCQA HEDIS measures applicable to pain medicine and opioid stewardship programmes, pulling numerator and denominator data from the registry to give a continuously updated compliance rate ahead of your annual HEDIS submission deadline.
| HEDIS Measure | Domain | PIN Data Source |
|---|---|---|
| Use of Opioids at High Dosage (UOD) | Medication Management | Registry prescription records |
| Use of Opioids from Multiple Providers (UOP) | Medication Management | Claims feed + registry |
| Follow-up After ED for AOD (FUA) | Behavioral Health | Claims feed |
| Medication Adherence — Pain (MAP) | Medication Management | Registry + claims PDC |
| Controlling High Blood Pressure (CBP) | Chronic Conditions | Registry clinical data |
| Diabetes Care (CDC) | Chronic Conditions | Registry clinical data |
1
Open Payer Performance → HEDIS Measures
Select the measurement year. PIN pre-loads NCQA's current-year measure specifications. Your current numerator, denominator, and rate are calculated from live registry data and display immediately.
2
Review the eligible population and exclusions
For each measure, click Denominator to verify the eligible patient population is correctly identified — confirming age ranges, diagnosis codes, and continuous enrollment criteria match NCQA specifications. Click Exclusions to review auto-applied exclusions and manually override any that are incorrect.
3
Close care gaps before submission
The Open Gaps tab lists patients in the denominator who have not yet met the numerator criteria. For each patient, PIN shows the specific event required to close the gap and the earliest date it could be completed given their care schedule. Assign gaps to care managers for outreach before the measurement period closes.
4
Generate the HEDIS submission file
When the measurement period closes, click Generate Submission. PIN produces an NCQA-formatted data file (IDSS-compatible XML and summary rate tables) ready for submission to your health plan or NCQA directly. Review the file against your payer's submission specifications before uploading.
Hybrid measures need medical record review Some HEDIS measures use a hybrid methodology — claims identify the eligible population but medical record review is required to confirm numerator events not captured in claims. PIN flags these patients so your abstractors know which records need manual review before the submission file is finalised.
Shared Savings
Model, track, and distribute ACO shared savings
PIN's Shared Savings module tracks expenditure against your ACO or MSSP benchmark, models projected year-end savings, and supports internal distribution calculations across participating providers — giving your finance and clinical leadership a single source of truth for shared savings performance.
1
Set up your ACO benchmark
Navigate to Payer Performance → Shared Savings → Configure Benchmark. Enter your CMS-assigned per-capita benchmark PMPM (per member per month), your assigned beneficiary count, the minimum savings rate (MSR) your contract requires before shared savings begin, and your sharing rate (the percentage of savings you retain). PIN uses these parameters to calculate your savings threshold and projected payout in real time.
2
Connect your claims expenditure feed
Link the CMS CCLF (Claim and Claim Line Feed) file or your payer's expenditure report under Admin → Integrations → Claims Feed. PIN ingests this monthly and plots your actual-vs-benchmark expenditure trend. Without the claims feed, only quality performance is trackable — expenditure data must come from claims.
3
Review the savings tracker
The Shared Savings dashboard shows cumulative expenditure vs. benchmark by month, your current savings or deficit position, projected year-end savings under three scenarios (current trajectory, optimistic, conservative), and the categories of spend driving variance — hospitalisation, ED use, specialist referrals, pharmacy.
4
Run a provider-level distribution model
Click Distribution Model to calculate how projected shared savings would be allocated across participating providers under your ACO's distribution methodology. Adjust weighting assumptions (equal share, quality-adjusted, attributed lives-weighted) and export the results as a PDF for your governance committee.
Pain medicine's impact on shared savings Appropriate pain management is among the highest-leverage interventions for ACO savings — reducing ED visits, avoidable admissions, and high-cost specialist utilisation. PIN's shared savings module can attribute expenditure reductions to specific care pathway changes, making the clinical case for pain programme investment quantifiable to payers.
Prior Authorisation
Manage, track, and streamline PA requests and appeals
PIN's Prior Authorisation module centralises PA request management — tracking submission status, payer response timelines, denial reasons, and appeal outcomes — and uses registry data to pre-populate clinical justification fields, reducing administrative burden on your clinical team.
1
Create a PA request from the patient record
Open the patient's record and click Prior Auth → + New Request. Select the treatment or procedure requiring authorisation. PIN auto-populates the clinical justification fields from the patient's registry data — diagnosis codes, prior treatments attempted (step therapy evidence), risk assessment scores, and functional status.
2
Review and submit to the payer
Review the pre-populated request, attach any additional clinical documentation (imaging, specialist letters), and select the submission method — electronic via your payer's portal integration, fax-to-digital, or manual. Click Submit. The request is logged with submission timestamp and assigned a PIN PA tracking number.
3
Track status and payer response
The PA Tracker shows all open requests with payer response timelines. Requests approaching the statutory response deadline (72 hours for urgent, 14 days for standard in most US states) are flagged in amber. When a payer responds — approved, partially approved, or denied — the status updates and a notification is sent to the requesting clinician.
4
Manage denials and file appeals
On a denial, click Appeal. PIN displays the payer's denial reason code, the applicable appeal deadline, and a pre-drafted appeal letter pulling the strongest supporting data from the patient's registry record. Edit as needed and submit. Appeal outcomes are tracked alongside the original PA case for longitudinal denial pattern analysis.
5
Review denial patterns in the PA Analytics dashboard
Navigate to PA → Analytics to see approval rates, average response times, and denial rates by payer, treatment type, and denial reason code. High denial rates for specific procedures or payers may indicate a need for updated clinical criteria letters or a payer relations conversation.
Gold carding Some payers offer gold card exemptions — waiving PA requirements for clinicians with consistently high approval rates. PIN can generate your approval rate report by payer on demand, which you can submit to support a gold card application.
Population Health
Stratify risk, identify gaps, and manage high-need cohorts
PIN's Population Health module segments your patient panel by risk tier, surfaces care gaps across the population, and enables targeted care management outreach — turning your registry data into a proactive clinical management tool rather than a retrospective reporting system.
1
View the Population Health dashboard
Navigate to Payer Performance → Population Health. The dashboard shows your full patient panel stratified into risk tiers, with counts, trend arrows, and the top care gaps driving risk in each tier. The default view is the current active panel; toggle to Attributed Beneficiaries to view your ACO or MA-attributed population.
2
Understand the risk stratification model
PIN stratifies patients into four tiers using a composite score derived from pain severity trajectory, functional status, comorbidity burden, opioid risk tier, and prior ED/hospitalisation history:
Critical
High acuity, deteriorating trajectory, or imminent risk event. Requires immediate case management contact within 48 hours.
High Risk
Elevated risk score with active care gaps. Weekly care manager touchpoint recommended.
Moderate
Stable with some care gaps. Monthly outreach and routine follow-up scheduling.
Low Risk
Well-controlled pain, no active gaps. Standard care schedule with annual reassessment.
3
Identify and action care gaps
Click Care Gaps to see a ranked list of open gaps across your population — by gap type, patient count, and estimated impact on quality scores. Assign batches of patients to care managers for outreach, set due dates, and track completion. Closed gaps auto-update the patient's risk score and VBP/HEDIS measures.
4
Build and export targeted outreach lists
Use the cohort builder to create targeted outreach lists — e.g. high-risk patients without a follow-up in 90+ days, or moderate-risk patients with an overdue opioid risk reassessment. Export as CSV for your care management team's outreach tools, or send PROM questionnaires directly via PIN's patient communication module.
Social determinants overlay If your institution submits SDOH screening data to PIN, the Population Health dashboard can overlay social risk factors (housing instability, food insecurity, transport barriers) onto the risk tier view — enabling prioritisation of patients who face both clinical and social barriers to engagement.
Outcome Contracting
Set milestones, track attainment, and report to payers
Outcome-based contracts tie payment to measurable clinical results — pain score reduction, functional improvement, opioid dose reduction, or return-to-work rates. PIN's Outcome Contracting module tracks attainment against defined milestones and generates the payer-facing evidence reports required for payment triggers.
1
Create an outcome contract record
Navigate to Payer Performance → Outcome Contracting → + New Contract. Enter the payer name, contract period, and the payment model — milestone-based (payment on outcome event), tiered (payment scales with outcome level), or hybrid (base fee plus outcome bonus).
2
Define outcome milestones
Add each contractually defined outcome milestone. For each milestone, specify the outcome measure (e.g. NRS reduction ≥30%), the measurement instrument (PIN validates against the PGIC, BPI, or NRS entries in the registry), the measurement timepoint (e.g. 3-month follow-up), and the payment amount or percentage triggered on attainment.
3
Enrol patients in the contract
Click Enrol Patients and select the patients whose treatment falls under this outcome contract. PIN records baseline outcome scores at enrolment from the patient's most recent registry assessment. All subsequent follow-up entries for enrolled patients are automatically tracked against the contract milestones.
4
Monitor milestone attainment in real time
The contract dashboard shows a live attainment rate for each milestone — percentage of enrolled patients who have reached the outcome, percentage approaching the measurement timepoint, and percentage at risk of not attaining by the deadline. Patients at risk of missing a milestone are surfaced for clinical review.
5
Generate the payer evidence report
When a payment trigger is met, click Generate Evidence Report. PIN produces a formatted report showing the enrolled cohort, baseline and follow-up outcome scores, attainment rate, and statistical confidence interval — everything a payer needs to process the outcome payment. Export as PDF or structured data file per your contract's submission requirements.
Use PIN data in contract negotiations Before entering an outcome contract, use PIN's historical registry data to model the expected attainment rate for the proposed milestones across similar patient cohorts. This protects your organisation from committing to outcome thresholds that the evidence suggests are unachievable in your patient population.
Claims Analytics
Analyse cost trends, utilisation, and coding patterns
PIN's Claims Analytics module ingests your payer-provided claims data and links it to registry clinical records, enabling clinical–financial analysis that neither claims nor registry data can support alone — answering questions like "which treatment pathways produce the lowest total cost of care?"
1
Connect your claims data source
Claims data enters PIN via one of three routes: CMS CCLF file upload (ACO/MSSP participants), direct payer claims feed via EDI 835/837 integration, or manual CSV upload using PIN's claims data template. Navigate to Admin → Integrations → Claims Feed to configure your connection. Claims data is encrypted in transit and stored separately from registry data — they are linked only within the analytics engine by de-identified patient ID.
2
Explore the Claims Analytics dashboard
Navigate to Payer Performance → Claims Analytics. The dashboard opens with four summary panels:
Total Cost of Care
PMPM expenditure by service category — inpatient, ED, specialist, pharmacy, ambulatory — benchmarked against payer and network averages
Utilisation Metrics
Admissions per 1,000, ED visits per 1,000, readmission rate, and avoidable utilisation flags (ambulatory care-sensitive conditions)
Pharmacy Spend
Drug-level spend breakdown, generic dispensing rate, high-cost medication flags, and adherence PDC rates cross-referenced with registry prescription data
Coding Analysis
HCC risk score trends, coding specificity rates, and diagnosis code gap analysis — identifying patients with clinical conditions in the registry that are not yet reflected in claims codes
3
Run a treatment pathway cost analysis
Click Pathway Analysis to compare total cost of care across different treatment pathways for a specific diagnosis group. PIN matches registry treatment pathway data with claims spend to calculate 12-month total cost of care per patient by pathway — factoring in procedure costs, medication, and downstream utilisation. Use this to demonstrate to payers the cost-effectiveness of interventional approaches versus medication-only management.
4
Identify HCC coding gaps
The coding gap analysis compares active diagnoses in PIN's clinical registry against what is coded in claims for each patient. Conditions documented in the registry but absent from recent claims represent potential HCC recapture opportunities — particularly relevant for patients with chronic pain comorbidities (depression, anxiety, diabetes, CRPS) that affect risk score and capitation rate. Click Export Coding Gap List for your coding team.
HCC coding must reflect documented clinical status PIN's coding gap analysis identifies documented conditions not yet reflected in claims — it does not suggest coding conditions that are not clinically documented. Code only what is documented, assessed, and addressed in the current period. Upcoding without clinical basis constitutes fraud.
All set You now have a complete picture of PIN's payer performance tracking suite — from value-based contract management through STAR and HEDIS improvement, shared savings modelling, PA workflow, population health stratification, outcome contracting, and claims-linked analytics. Use these tools together for a unified view of your clinical and financial performance.