Payment Calculator

Customer Persona: MetaWell Care Segment A Consumer Growth Brand ▼

Tracks
eCKM + MSK

Stage
9 months in (Apr 2027)

Enrolled
~150 patients

Ops Model
Software-led

Storyline
"The Hidden SSA Trap"

Company Profile

Company

MetaWell Care

Clinical arm of MetaWell Health (~$15M revenue, $134M total funding, Series D Jan 2025)

What They Do

Virtual nutrition counseling from Registered Dietitians (1:1 video sessions) and app-based physical therapy rehab programs. Consumer fitness app has 12-20M users. Clinical arm is much smaller — estimated 2,000-8,000 active patients, all commercial insurance.

Clinical Workforce	~20-40 RDs (mostly PRN, 15-25 hrs/week), ~5-15 PTs. No MDs, no prescribers.
Primary Markets	FL, CA, TX, NY (city-level marketing pages). Licensed in 12-19 states.
Medicare History	No organizational NPI registered. "MetaWell Medicare Care of New York" entity exists but no billing history.
Devices	None — no RPM devices, no BP cuffs, no connected scales.
Clinical Revenue	Estimated $2-5M (RD visits billed to commercial insurance)

1Access Segmentation

Segment	A Consumer Growth Brand
Mindset	Growth-first Marketer
Ops Model	Software-led
GTM Orientation	Consumer-first
Price Model	PMPM or % rev share, $8-12 PMPM
Friction Point	Consumer fitness platform with no Medicare targeting layer; high CAC for Medicare patient acquisition

Solution Scope vs. Track Requirements

Track	Condition	MetaWell Capability	Gap
eCKM	Hypertension	Weak — no BP monitoring, no prescribing	Major — patients see PCP
eCKM	Dyslipidemia	Moderate — dietary counseling	No medication mgmt
eCKM	Obesity	Strong — core RD competency	Low
eCKM	Prediabetes	Moderate — nutrition counseling	No glucose monitoring
MSK	Chronic MSK Pain	Moderate — app-based PT	Self-guided only, no live PT

Our Story

Setting the Scene

MetaWell spent months 1-3 building Medicare infrastructure from scratch — NPI enrollment, provider credentialing, billing system setup. Real enrollment didn't start until month 4. Their DTC marketing (Meta ads, consumer-first playbook) is driving acquisition, but they're learning that marketing to 65+ Medicare beneficiaries is a different game than their consumer fitness app audience.

By month 9, they've enrolled ~150 patients: 105 in eCKM (primarily obesity and nutrition counseling) and 45 in MSK (app-based physical therapy). Enrollment is ramping — 25-30 new patients per month.

The Hidden SSA Trap

MetaWell enrolls patients for obesity counseling — but those same patients often have a PCP or cardiologist billing RPM/CCM for hypertension management. MetaWell has no visibility into what other providers are billing for their patients.

ACCESS Revenue Calculator eCKM Track — MetaWell Care — 9 months

Figures use synthetic sample data for illustration.

Enrolled (eCKM) iTotal patients currently enrolled in the eCKM track. Includes initial and follow-on period patients. Growth driven by DTC acquisition (Meta ads).

105

+30 this month

Gross Annual Revenue iGross = enrolled x annual rate. This is the total payment CMS would make if there were no withhold. Actual cash received is 50% monthly + quarterly reconciliation of the withheld 50%.

$36,540

$30/patient/month

SSR iSubstitute Spend Rate. Percentage of enrolled patients who are not receiving substitute services from another provider. Threshold: 90%. Below threshold means too many patients have another provider billing RPM/CCM for the same conditions. Detected via CCW bene match (claims data).

78%

Below 90% threshold

OAR iOutcome Attainment Rate. Percentage of patients meeting ALL required OAP measures for their track/condition. Threshold: 50%. A patient "meets" a measure if they hit either the control target OR the minimum improvement target. Driven by patient engagement — disengaged patients almost never meet measures.

52%

Above 50% threshold

Penalty Exposure iProjected quarterly penalty. Applied penalty = MAX(clinical, SSA) — not additive. Clinical penalty (from OAR) caps at 50% of withhold. SSA penalty (from SSR) caps at 25%. Only the larger of the two applies.

$2,190

~6% of gross revenue

Session Attendance iPercentage of enrolled patients actively attending scheduled dietitian sessions. Drives OAR — patients who don't attend sessions rarely meet outcome measures.

65%

Actively attending monthly

Activation Rate iPercentage of enrolled patients who completed onboarding and attended at least one clinical session. Patients who never activate are almost certain to fail OAP measures.

82%

Completed onboarding

At-Risk Patients iPatients with no clinical session or app activity in 30+ days. These patients are likely to: (1) fail OAP measures, dragging down OAR, and (2) seek care elsewhere, potentially triggering substitute services (SSR impact).

No session in 30+ days

Avg Sessions / Mo iAverage number of dietitian sessions attended per patient per month. Higher session frequency correlates with better OAP measure outcomes. Target of 2.0 based on clinical protocol.

1.4

Target: 2.0

Net Growth iMonthly net enrollment growth rate (3-month trailing average). Includes new enrollments minus churn. Positive = growing panel. Negative = losing patients faster than acquiring.

+15%

Monthly (3-mo trailing)

Monthly Revenue — eCKM Track Monthly cash (50%) + quarterly withhold reconciliation

Net Enrollment Growth Actual: ~15%/mo

+15%

Monthly net growth rate (includes churn)

SSR (Substitute Spend) Actual: 78%

78%

Threshold: 90% — below triggers penalty

OAR (Outcomes) Actual: 52%

52%

Threshold: 50% — below triggers penalty

Monthly cash (50%) Projected monthly cash Quarterly withhold returned Penalty deducted 3-mo trailing avg Projected trend

Export Export to Google Sheets

Generates a Google Sheet with your full data and calculations:
• Data tabs — patient records, CCW match results, CMS rates
• Calculator tabs — formulas driving this chart, quarterly reconciliation
• Scenarios tab — editable workspace for custom what-if modeling

All formulas are transparent and editable. Snapshot at export time — export again for fresh data.

Monthly Cash Flow Detail ▼

Month	Enrolled	New	Gross Payment	Withhold (50%)	Net Cash	SSR	OAR	Status
Jul 2026	3	3	$90	$45	$45	—	—	Ramp
Aug 2026	7	4	$210	$105	$105	—	—	Ramp
Sep 2026	10	3	$300	$150	$150	82%	—	Ramp
Q1 Reconciliation			$300 pool	+$300	—	—	Full return
Oct 2026	22	12	$660	$330	$330	80%	48%	SSR watch
Nov 2026	37	15	$1,110	$555	$555	79%	50%	SSR watch
Dec 2026	57	20	$1,710	$855	$855	78%	51%	SSR below
Q2 Reconciliation			$1,740 pool	+$1,305	—	—	SSA penalty: $435
Jan 2027	72	15	$2,160	$1,080	$1,080	78%	52%	SSR below
Feb 2027	87	15	$2,610	$1,305	$1,305	77%	52%	SSR below
Mar 2027	105	18	$3,150	$1,575	$1,575	78%	52%	SSR below
Q3 Reconciliation			$3,960 pool	+$2,970	—	—	SSA penalty: $990

How Payments Work The 50/50 withhold and performance penalties, in plain terms ▼

How cash flows — monthly payments, quarterly true-up

ACCESS pays monthly, but half of every payment is withheld and reconciled quarterly against performance. Revenue therefore comes in two streams: a steady monthly cash floor (the 50% paid right away), and quarterly true-ups when the withheld half is returned — minus any penalties.

That's what creates the jagged pattern in the chart above: dark blue bars are the monthly cash floor (always received), orange bars are the quarterly withhold returned, and red slices are penalty deductions.

Payment per patient, by track

Each patient's monthly payment is the annual rate divided by 12, split 50/50 between immediate cash and the withheld pool.

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.

How performance affects what you keep

Each quarter, two performance tests decide how much of the withheld pool comes back:

SSR — Substitute Spend Rate (threshold 90%). The share of your patients with no other provider billing care management for the same conditions. Below 90%, a penalty of up to 25% of the withhold applies.
OAR — Outcome Attainment Rate (threshold 50%). The share of patients meeting all required outcome measures for their track. Below 50%, a penalty of up to 50% of the withhold applies.

The two penalties are not additive — only the larger of them is applied. So the most you can lose in a quarter is 50% of that quarter's withheld pool, never both penalties stacked.

What counts as "substitute spend" — the hidden risk

A substitute service is another Medicare provider billing care-management codes — RPM, CCM, BHI, PCM — for conditions in the same ACCESS track. It's not "seeing another doctor"; it's specifically another provider being paid to manage the same conditions you enrolled the patient for.

Customers usually can't see this on their own — it only shows up in Medicare claims. Surfacing it early is what turns a surprise quarterly penalty into something you can manage ahead of time.