CALC-01 Payment Timing — How Cash Actually Flows
ACCESS payments are monthly, but with a 50% withhold that reconciles quarterly.
This creates two distinct cash flow streams:
Stream 1 — Monthly cash (every month):
CMS pays 1/12 of the annual rate per patient per month
Provider receives 50% immediately, 50% is withheld
net_monthly_cash = enrolled_patients * (annual_rate / 12) * 0.50
Stream 2 — Quarterly reconciliation (every 3 months):
The accumulated 50% withhold pool is evaluated against OAR and SSR
If performance meets thresholds: withhold is returned (partially or fully)
If not: penalties are deducted, remainder is returned
This creates the "jagged" revenue pattern — steady monthly baseline
punctuated by quarterly spikes (or dips)
The chart above shows this pattern: dark blue bars are the monthly cash floor (always received),
orange bars are the quarterly withhold return, and red slices are penalty deductions.
CALC-02 Monthly Payment per Patient
monthly_payment = (base_annual_rate + rural_addon) / 12
withhold = monthly_payment * 0.50
net_cash = monthly_payment - withhold
| Track | Annual Rate (Initial) | Monthly | Cash (50%) | Withheld (50%) |
|---|
| eCKM | $360 | $30.00 | $15.00 | $15.00 |
| CKM | $420 | $35.00 | $17.50 | $17.50 |
| MSK | $180 | $15.00 | $7.50 | $7.50 |
| BH | $180 | $15.00 | $7.50 | $7.50 |
Follow-on rates are half of initial. Rural add-on = $15/yr for eCKM/CKM only. Multi-track discount = 5% on lowest-cost track.
CALC-03 Monthly Org Revenue
gross_monthly = SUM(monthly_payment) for all enrolled patients
withhold_monthly = gross_monthly * 0.50
net_monthly_cash = gross_monthly - withhold_monthly
Each patient contributes based on their track, period (initial vs. follow-on), and rural status.
The monthly total ramps as new patients enroll — this is the gradual upward trend in the chart.
CALC-04 Quarterly Reconciliation
withhold_pool = SUM(withhold_monthly) for months in quarter
clinical_penalty = IF oar_rate >= 0.50 THEN $0
ELSE MIN((1 - oar_rate / 0.50), 0.50) * withhold_pool
ssa_penalty = IF ssr_rate >= 0.90 THEN $0
ELSE MIN((1 - ssr_rate / 0.90), 0.25) * withhold_pool
applied_penalty = MAX(clinical_penalty, ssa_penalty)
reconciliation_payment = withhold_pool - applied_penalty
Key nuance: Penalties are NOT additive — the higher of clinical or SSA is applied, not both.
OAR threshold = 50%. SSR threshold = 90%. Clinical penalty caps at 50% of withhold. SSA penalty caps at 25%.
So the maximum possible penalty is 50% of the withhold pool (if OAR is very low), not 75%.
CALC-05 Substitute Spend Rate (SSR)
SSR measures how many of your patients are "clean" — meaning no other
provider is billing care management services for the same conditions. A high SSR is good.
ssr_rate = patients_WITHOUT_substitute_services / total_enrolled
Threshold: 90%
- SSR >= 90% → no penalty (at most 10% of patients have substitute services)
- SSR < 90% → penalty scales linearly, capped at 25% of withhold
Example at SSR = 78% (MetaWell):
- 78% of patients are clean, 22% have substitute services
- 22% exceeds the 10% tolerance
- Penalty = MIN((1 - 0.78/0.90), 0.25) * withhold = 13.3% of withhold
What counts as a substitute service: Another Medicare provider (different NPI) billing
specific CPT codes — RPM (99453-99458), CCM (99490-99491), BHI, PCM — for conditions in the same ACCESS track.
CMS publishes ~550 specific HCPCS codes that trigger SSA. It's not just "seeing another doctor" — it's
specifically another provider billing care management codes for overlapping conditions.
Why this matters for MetaWell: MetaWell can't manage hypertension (no BP monitoring, no prescribers).
Their patients' PCPs continue billing RPM for blood pressure monitoring. MetaWell has no visibility into this —
only the CCW bene match reveals which patients have substitute services active.
Why 90% is reasonable: CMS is saying "if you enroll a patient, you should actually
be their care manager." The 10% tolerance covers edge cases (specialist flare-ups, transitions). The structural
problem is when a company enrolls patients for one condition but can't manage the others in the same track.
CALC-06 Outcome Attainment Rate (OAR)
oar_rate = patients_meeting_all_measures / patients_with_measures_due
A patient "meets" a measure if EITHER:
- Control target is met (e.g., BP < 130), OR
- Minimum improvement target is met (e.g., 15 mmHg reduction)
Each track has specific OAP measures. A patient must meet ALL required measures
for their track/condition to count toward OAR. Engagement directly drives this — disengaged
patients almost never meet measures.
CALC-07 Projection Bands
// Optimistic: full withhold returned
upper_band = gross_revenue (no penalty)
// Expected: current OAR/SSR trajectory
expected = gross_revenue - projected_penalty(current_oar, current_ssr)
// Pessimistic: max penalty
lower_band = gross_revenue - max_penalty(oar=0, ssr=0)
// Growth extrapolation
future_enrolled = current + (monthly_enrollment_rate * months_forward)
Projection uses current enrollment rate extrapolated forward. OAR and SSR assumptions
can be adjusted (what-if). Band width reflects the range of penalty outcomes.
CALC-08 Engagement Impact
// Engagement drives OAR
oar_engaged_patients = 0.68 // engaged patients meet measures at higher rate
oar_disengaged_patients = 0.22 // disengaged rarely meet measures
blended_oar = (engaged_count * oar_engaged) + (disengaged_count * oar_disengaged) / total
// Engagement drives RTM eligibility
rtm_eligible = patients WHERE app_active_days >= 16
rtm_monthly_revenue = rtm_eligible * avg_rtm_per_patient
Engagement is the hidden multiplier. It affects ACCESS revenue (via OAR) AND RTM revenue
(via compliance day thresholds). Re-engaging 10 patients can be worth more than enrolling 10 new ones.