CASE STUDY

Making CCLF Data Actionable for ACO REACH

How we helped a mid-sized Medicare Advantage provider unify fragmented claims data and see the full financial picture

Client Background

Client: ACO REACH Management Organization
Reach: Multiple provider groups across various EHR systems
Population Covered: 20,000+ Medicare patients across diverse practices
Project Duration: 4 weeks (initial version)

The Challenge

Challenge:
For ACO REACH Management Organizations, the data landscape often feels upside down.

Unlike Medicare Advantage groups, ACO REACH entities typically receive well-structured claims data (CCLF files) directly from CMS. But here’s the twist: the provider practices they support are fragmented—each using different EHR systems, with widely varying patient volumes and levels of operational sophistication.

The client came to us with a simple but critical problem:

They didn’t need more data—they needed clarity, structure, and insight.

“ We have all this CMS data, but we don’t know how to turn it into something useful for our practices. It’s just not actionable.”

Our Approach

Valuable Insight focused on what was available and consistent: CMS CCLF claims.

We built a custom data categorization framework, designed to break raw CCLF claims into structured, clinically meaningful groupings—procedures, diagnoses, places of service, etc.—tailored to ACO management needs.

Then, we layered on our high-risk patient identification model, helping the client surface:

  • High-cost outliers

  • Patients with frequent acute care usage

  • Providers with opportunity to intervene

One example: within the first run, we helped identify a single patient whose unmanaged utilization had already cost over $500,000—actionable information the organization had never been able to isolate before.

The Outcome

$500K+

Flagged in avoidable cost — one patient, one breakthrough.

4 Weeks

From raw CMS data to working tool — built and delivered fast.

By staying focused on available CMS data—and skipping expensive off-the-shelf tools—we delivered a working solution in under 4 weeks:

  • Custom high-risk tagging system built on CCLF files

  • Insights surfaced by provider and practice

  • Fully integrated into their internal reporting suite

The client avoided the cost and rigidity of third-party software, gained better insight into their population, and empowered clinical leads to act.

What This Shows

You don’t need perfect data to make powerful decisions.

With the right strategy, CMS claims can become a source of clinical insight, cost control, and operational focus.

“This is the first time we’ve had a clean view of all our spend. I can finally stop digging through spreadsheets.”

— Director of Medical Economics, Medicare Advantage Provider Group