PROVIDER NETWORK · LATIN AMERICA
Background
This provider network delivers primary and preventive care under a prospective global payment with a single payer. The cost of care sits on the network’s side of the contract.
The payer scores the network on its compliance with the national preventive care pathway, and that score sets a payment discount and the network’s ranking against peer networks.
Challenge
The preventive pathway assigns each patient a set of activities by age, sex, and condition: consultations, laboratory tests, vaccinations, and procedures, each at a defined interval. Clinical guidelines add a second requirement: episodes of common conditions follow a stepped protocol that places conservative management ahead of imaging and referral. The network tracked the first requirement in spreadsheets and dashboards built on encounter data from its legacy systems, with laboratory results held in a separate system. The second requirement lived inside each clinician’s judgment. The finest grain the team could see was a percentage per activity.
That view leaked in five ways. Patients with pending activities surfaced only when the payer’s validator measured coverage. Activities performed outside protocol parameters, a screening repeated ahead of schedule or done outside its age range, brought zero credit after the network had paid for them. Tests and procedures ordered for a chronic condition could have credited the pathway and were ordered again, because the records sat in separate systems. Clinicians with 20 minutes per consult reordered what the patient already had. And episodes such as an uncomplicated back pain went to imaging ahead of the conservative phase, at a cost the guideline would have deferred. Two of the five leaks hit the payer score. The other three landed on medical cost.
Solution
Falcon’s agents read the visit records, laboratory results, and procedure reports the network’s systems already produce. Each night they rebuild one ledger per patient and evaluate it on two axes: coverage, which pathway activities are due and what evidence exists for each; and sequence, whether each episode followed its stepped protocol. By morning the worklists refresh: a credit queue for the reporting team, a reschedule queue for activities performed outside parameters, an outreach queue per site that leads with patients who already have a visit scheduled, and a pre-visit summary of what each patient already has. Episodes that escalated ahead of the guideline route to medical direction. When the clinical team corrects a finding, the next run carries the correction into every ledger.
The engagement began with a retrospective: a sample of active patients, three to five years of history each, evaluated end to end and reviewed by the network’s clinical team before the engine ran across the full population.
Mechanism
Fig. 01 · One ledger per patient, checked for coverage and for sequence
Results
Next steps