Health Plans & Payers
Transitional Care ManagementA problem payers can solve even though they do not deliver it
Health plans do not deliver post-discharge care, and CMS does not require them to. Yet they still bear the financial risk. TCM execution varies across their networks, depending on which practices have the infrastructure to deliver it. Nationally, roughly one in ten eligible Medicare discharges results in a billed TCM service.
Execution
Why TCM execution is inconsistent across your network, and the value of fixing it
The problem is not clinical judgment. It is infrastructure. Some practices have the volume, staff and systems to justify building and maintaining a dedicated TCM operation. But most do not.
For a health plan, that creates an inconsistent network-wide result. You cannot solve it practice by practice. If every practice has to build its own staffing, workflows, and systems, TCM performance will remain dependent on which practices happen to have the resources to do it.
Praventa's TCM infrastructure solves that problem without requiring the plan or the practice to build anything new.
We provide the infrastructure that identifies the discharge, reaches the member within the required two-business-day window, and supports pharmacist-led medication reconciliation and documentation. Once reconciliation is complete, a Praventa nurse practitioner conducts the required face-to-face visit by telehealth, inside the seven or fourteen day window that applies to the member's complexity. The practice is not asked to absorb that visit into its own schedule, which is the constraint that stops most post-discharge programs from running on time. We do this across the network, regardless of the size or capabilities of the individual practice. The practice keeps the patient relationship. What changes is consistency. TCM happens across the network, not just at the practices that already have the infrastructure to make it happen.
The financial value of TCM for plans below four stars.
For Medicare Advantage plans below four stars, moving across the four-star threshold can materially change the economics of the contract, with the potential to create millions of dollars in additional annual value at scale.
That makes Transitional Care Management particularly valuable for plans sitting below the four-star threshold. Consistent execution during the critical period following a hospital or skilled-nursing discharge can improve medication adherence, care coordination, follow-up, and ultimately the outcomes that influence plan performance.
The opportunity is especially significant for plans at 3.0–3.5 stars. These contracts have more than a clinical opportunity; they have a meaningful economic incentive to improve performance and move toward the four-star threshold.
TCM creates value for every Medicare Advantage plan. But for plans below four stars, the potential financial impact can be substantially greater because improved performance may contribute to crossing a threshold that changes the economics of the entire contract.
Which measures this actually touches.
Post-discharge work and ongoing medication management are where several Star measures are physically produced. These are the ones a complete program reaches.
Transitions of Care
Medication adherence
Member experience
Claims data alone do not tell the complete picture
What can claims data tell a health plan, and what it can not?
Claims establish that an event occurred and that a service was billed for it. They are an accurate record of transactions and a poor record of clinical work.
A claim for a transitional care management service tells a plan that a practice reported the service and met the conditions for reporting it. It does not say what the medication reconciliation found, whether a duplicate therapy was caught, whether the member understood the discharge instructions, or whether anything was escalated to the prescriber.
That gap matters most precisely where the spend is highest. A plan looking at a readmission after a billed post-discharge service cannot tell from claims whether the intervention was thorough and the readmission was unavoidable, or whether the service was minimally satisfied and the readmission was foreseeable.
The absence is structural rather than a data quality problem. Claims were built to adjudicate payment. No amount of cleaning turns them into a record of clinical judgment.
The Layer
What is an intervention data layer?
A structured record of what was actually done between the events that claims describe, captured as the work happens rather than reconstructed from billing afterward.
The unit is the intervention, not the claim. Each post-discharge episode carries the attempts made, the problems found, what was resolved, what was escalated and what remained open at the end of the period. Because it is captured in the workflow, it exists whether or not the episode ended in a billable service.
That last point is the one plans tend to find most useful. A member who was contacted three times and never reached generates no claim, and therefore no claims-based evidence that anything was attempted. In an intervention record, that member is visible, and so is the reason the episode failed.
Discharge detection
When a member leaves an inpatient or observation stay, and from where.
Contact attempts
Every attempt made, when it was made, and whether it reached the member.
Medication reconciliation
What the member is actually taking against what was prescribed at discharge.
Problems identified
The clinical issues found during the intervention, captured as structured data.
Resolution
Whether each identified problem was closed, and what closed it.
Recommended follow-up completion
Whether a follow-up identified during the episode, such as a specialist visit, repeat labs or a return visit, actually occurred, and when.
Escalation
What was escalated, to whom, and what came back.
That data does not stay inside Praventa's systems. It is available through API connectivity built to integrate directly with a health plan's population health platform, scoped to each partner's specific system, so stratification, care management, and gap-closure workflows can run on what was actually done during a discharge episode rather than waiting on a claim that may never arrive.
Action
What can a health plan do with intervention data?
Six things, in roughly the order a plan tends to want them. The first three change how resources are directed. The last three change what can be demonstrated to a regulator, a board or a delegated partner.
01
Identify
Which discharges carry the highest readmission risk, before the window closes rather than after it.
02
Target
Direct intervention to the members where it changes the outcome, instead of spreading it evenly.
03
Optimize
See which contracted practices are performing the work, and where the gaps sit.
04
Measure
Separate the members who received a complete intervention from those who received a billed one.
05
Prove
Connect the intervention to the utilization that followed, at the member level.
06
Scale
Extend the same structure across the network without rebuilding it per practice.
The Use Case
Where does transitional care management fit?
It is the natural starting point, because the population is defined by an event, the window is short and fixed, and the outcome of interest is measured in the same 30 days.
Every element a plan wants to evaluate is present in a compressed period. A discharge creates the cohort. The interactive contact requirement creates a measurable, time-stamped action. The follow-up visit creates a second one. The 30 day period creates a natural boundary for attributing what followed.
Transitional care management is also the program where the gap between billed and delivered is widest. Roughly one in ten eligible Medicare discharges nationally receives a billed transitional care management service, so a plan working only from claims is reasoning about a small and unrepresentative slice of its own discharged population.
Note that the service is billed by the outpatient practice rather than by the plan or the hospital. A plan does not report these codes. What it gains is visibility into whether the work behind them happened across its contracted network, and what it produced.
Measurement
How should a plan measure whether an intervention worked?
Start by separating three things that are routinely reported as one: whether the service was billed, whether the work was complete, and whether the member's trajectory changed.
A completion rate answers the first two at best. It confirms a billable service occurred and, if the underlying record is structured, that its required elements were performed. It says nothing about the third.
Connecting intervention to outcome requires the intervention to be recorded at a granularity that supports comparison: which members received a complete intervention, which received a partial one, which received none, and what utilization followed each group. Where a plan holds that alongside its own claims, the comparison becomes possible.
Be careful about how the result is framed. Applying a national readmission rate to a specific attributed population, or presenting gross avoided utilization as a return, will not survive scrutiny from an actuary. The defensible version states the population, the comparison group, the period and the assumption behind every step.
Common Questions
Related questions
Can a health plan see whether a post-discharge call actually happened?
Not from claims. A claim confirms that a practice reported a service and attested to meeting its conditions. Whether contact was attempted three times and failed, or succeeded on the first call and surfaced a medication problem, produces the same claim. Seeing the difference requires the intervention to be recorded where it happens.
What is the difference between a completion rate and an outcome?
A completion rate says a service was finished. An outcome says something changed for the member. A program can report a high completion rate while producing no measurable change in utilization, and the two are frequently reported as though the first implies the second.
Does transitional care management billing data show what was done during the intervention?
No. The codes encode the level of medical decision making and the timing of the face-to-face visit. They do not encode what the medication reconciliation found, what was escalated, or what was left unresolved when the period closed.
How does this work across a delegated or contracted provider network?
The work that is uniform across practices, meaning discharge notification, the two business day contact and episode tracking, can be operated centrally. The face-to-face visit and the claim stay with the practice, because only one practitioner may report the service for a given discharge. That division is what allows a consistent record across a network without standardizing every practice's internal workflow.
Can this run alongside an existing care management vendor?
Yes, and it frequently has to. Augmentation is a narrower decision than replacement: the constraint is that the claim stays with one billing practitioner, so the work can be divided but the reporting cannot be duplicated.
Does a health plan need to change its claims systems?
No. The intervention data layer runs alongside your existing claims systems rather than replacing them, and connects to your population health platform through API integration, scoped to your specific system. See how that data is structured above.
Why does post-discharge performance vary so much across a contracted network?
Because the work depends on infrastructure the individual practice has to own. Identifying a discharge in time, reaching the patient inside two business days, reconciling medications and documenting it to survive review are systems problems, not clinical ones, and most practices do not have the volume to justify building that capability. Performance therefore tracks which practices happen to have the resources, which is why network-wide results look uneven even where clinical quality is not.
Can a health plan deliver transitional care management itself?
No, and it is not designed to. Only one practitioner may report the service for a given discharge, the face-to-face visit must come from the billing practitioner, and the supporting documentation lives in the practice's record. A plan carries the exposure to what happens after discharge without being able to furnish the service, which is the gap that makes plan-enabled infrastructure inside provider practices the workable answer.
How quickly does intervention data reach the plan compared with claims?
Claims arrive after adjudication, which is typically well after the post-discharge window has closed. Intervention data is captured as the work happens and moves through API connectivity into the plan's population health platform, scoped to that platform, so stratification and care management can act on a member's actual post-discharge status while the thirty-day window is still open rather than reconstructing it from billing months later.
What happens to members who are never reached?
They are the most important cases and the ones claims cannot show. A member contacted three times without success generates no claim, so claims-based reporting holds no evidence that anything was attempted. In an intervention record that member is visible, the attempts are visible, and the reason the episode failed is visible, which is what lets a plan redirect outreach rather than assume coverage.
This page describes how post-discharge intervention data is captured and what a health plan can do with it. It does not state payment rates or projected savings. Any financial model should be built on the plan's own population and contract terms rather than on national averages.
Talk to us about your discharged population
Praventa operates transitional care programs with its own clinical team and licenses the same platform to organizations running them in-house. Tell us how your network is structured and we will tell you which model fits.