OIX Feature Breakdown & ROI Calculator

Complete visualization of all 5 modules, competitive advantages, and financial impact

The Five Failure Modes & OIX Modules
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Module 01: Alignment

Formal enrollment with CMS (Payment eligibility foundation)
Why Build It
Payment Eligibility
Patient must be formally aligned to receive OAP. Misalignment = 100% payment lost.
How It Works
CMS Alignment API
Call $align API with patient details → CMS confirms → OAP begins
Customer Benefit
No Payment Loss
Dashboard shows alignment status; catches errors before CMS
Patient Benefit
Informed Consent
Clear 12-month commitment; can switch after 90 days
Data Sources
CMS API, EHR
Patient demographics, eligibility, consent records
Infra Cost (Annual)
$10–15K
CMS API + database + monitoring

Financial Impact

Risk Exposure: 1% misalignment on 50K patients = 500 × $300 = $150K lost
OIX Value: Prevents misalignment errors; catch-rate >99%
🧪

Module 02: Measure Capture

Baseline & follow-up lab collection (Outcome calculability)
Why Build It
Outcome Data
CMS requires baseline + follow-up labs. Missing = outcome can't be calculated = withheld payment.
How It Works
Auto Lab Orders + Ingestion
Day 1: Generate orders → Day 30: Capture labs → Day 180/365: Follow-ups
Customer Benefit
Capture Assurance
Automated ordering; deadline tracking; missing lab alerts
Patient Benefit
Timely Orders
No manual chasing; clear communication about why labs matter
Data Sources
EHR, Lab Networks
FHIR Observations, HL7v2 ORU messages, lab results
Infra Cost (Annual)
$20–30K
HL7v2 listener + FHIR endpoint + lab connectors

Financial Impact

Risk Exposure: 5% missing baseline labs on 50K = 2.5K × $300 × 50% withheld = $375K lost
OIX Value: Improve capture from 90% → 98% = $1.5M saved
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Module 03: Outcome Prediction

ML-based early intervention timing (Care team effectiveness)
Why Build It
Early Intervention
20-point attainment lift requires early targeting. Without prediction, intervention is too late.
How It Works
ML Risk Scoring
Ingest baseline → Run ML model → Generate risk scores → Weekly updates → Route to care programs
Customer Benefit
Attainment Lift
Identify top 20% at-risk patients by week 2; escalate before they fail
Patient Benefit
Proactive Care
Early outreach (not crisis care); matched to right intervention
Data Sources
EHR, Wearables, Claims
Observations, vitals, medication fills, engagement data
Infra Cost (Annual)
$30–50K
ML model training + GPU compute + feature engineering

Financial Impact

Attainment Baseline: Without prediction, 40% hit outcome targets
With Prediction: 60% hit targets (20-point lift)
ROI: 50K × $300 × 50% withheld × 20% lift = $1.5M incremental OAP
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Module 04: Substitute-Spend Watch 🏰 YOUR MOAT

Real-time monitoring of duplicate services (Penalty avoidance)
Why Build It
Invisible Penalty
If >10% of your patients get services from other vendors, CMS claws back -25% of ALL OAP.
How It Works
BCDA Claims Monitoring
Daily: Pull claims from BCDA → Flag CCM/RPM/PIN/BHI from OTHER providers → Alert if trending to >10%
Customer Benefit
Penalty Avoidance
Real-time alerts; know substitute-spend rate daily; avoid $3.75M clawback
Patient Benefit
No Duplication
Continuous care coordination; avoid conflicting instructions from 2+ vendors
Data Sources
BCDA (Live Claims)
Real-time Medicare claims for all aligned beneficiaries; daily refresh
Infra Cost (Annual)
$15–25K
BCDA API + claims ingestion + alerting engine

Financial Impact

Penalty Exposure: If substitute-spend >10%, lose 25% of total OAP
Example: 50K × $300 = $15M OAP; 25% penalty = $3.75M clawback
OIX Value: Real-time detection + intervention prevents penalty entirely
ROI: $3.75M saved / $20K cost = 187×
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Module 05: Revenue Assurance Ledger

Financial visibility & forecasting (CFO dashboard)
Why Build It
Cash Forecasting
OAP is outcome-gated; 50% withheld. CFO can't forecast cash without knowing capture rate.
How It Works
Aggregation Engine
Combine all 5 modules → Generate daily ledger: Captured + At-Risk + Lost + Pending
Customer Benefit
Financial Clarity
Real-time OAP pipeline; forecasts by failure mode; month-12 surprise eliminated
Patient Benefit
Outcome Tracking
Patient dashboard shows progress on outcome targets; transparent about where they stand
Data Sources
All 5 Modules Feed
Alignment status + measure capture + predictions + substitute-spend + submissions
Infra Cost (Annual)
$10–20K
Dashboard + analytics + reporting + CMS audit trail

Financial Impact

Visibility Benefit: Forecast accuracy ±2% (vs. competitors at ±20%)
Operational Impact: Know early if trending to lose revenue; hire staff for QA; avoid surprises
Example: If Module 04 was going to cause $500K loss, you'd know by month 3 and fix it
ROI Calculator: What's OIX Worth to Your Customer?

Customize Your Scenario

Total Eligible OAP
$15M
Annual opportunity
Current Captured
$12.2M
Without OIX
OIX Incremental Gain
$2.1M
From all modules combined
OIX Annual Cost
$80K
Platform + infra
Net OAP Impact
+$2.02M
Year 1 incremental
ROI
2,525%
Cost of OIX recovered in 15 days
Key Insight: With standard scenario (50K patients, $300 base OAP), OIX generates $2–3M in incremental OAP while costing $80K/year. That's a 25–37× return on investment.
Competitive Landscape: Who Does What
Company/Platform Alignment Measure Capture Outcome Prediction Substitute-Spend Watch Revenue Ledger Model Notes
OIX (You) ✓ ✓ ✓ ✓✓ ✓ Vendor (neutral) All 5 modules; only vendor with substitute-spend; $1.75 PMPM
Innovaccer ✓ ✓ ✓✓ ✗ ~ Participant (operator) Competes WITH orgs, not FOR orgs; not available as vendor to most
Verily ~ ~ ✓✓ ✗ ✗ Data platform Precision health research focus; not operations/cash flow
Health Catalyst ✗ ✓ ✓ ✗ ✓ Analytics Broad analytics; not ACCESS-specific; no real-time BCDA
Arcadia Analytics ✗ ✓ ✓ ✗ ~ Population health Good for general PHM; not OAP-specific
Epic/Cerner Native ~ ~ ✗ ✗ ✗ EHR vendor Not outcome-specific; no BCDA integration
Noom/Withings ✗ ~ ✓ ✗ ✗ Single-track vendor Device-focused; not integrated with healthcare ops
Key Insight: You're the only platform providing all 5 modules in one integrated package. Substitute-spend watch (Module 04) is completely uncontested—worth $3.75M to avoid clawback. Competitors are either (a) too broad (Health Catalyst), (b) too specific (single-track), or (c) competitors not vendors (Innovaccer).
Data Flow Architecture

Patient Data Ingest Pipeline

EHR
Patient demographics, diagnoses, labs, vitals
→
OIX Ingestion
FHIR normalization, HL7v2 parsing
→
Data Lake
Patient records, observations, encounters
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5 Modules
Alignment, Capture, Prediction, Substitute-Spend, Ledger
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Dashboards
CFO, Clinical, Patient, CMS

Key Data Sources by Module

Module Primary Source Secondary Sources Frequency
Module 01: Alignment CMS ACCESS API EHR (eligibility check) On-demand
Module 02: Capture EHR (FHIR Observation) Lab networks (HL7v2), BCDA Daily
Module 03: Prediction EHR observations Wearables, claims, patient app Real-time / Daily
Module 04: Substitute-Spend BCDA (Live Claims) Your observation data Daily
Module 05: Ledger All modules aggregate CMS submission responses Daily
Infrastructure & Operating Costs
Costs shown are per-customer annual infra spend. Platform development (fixed cost) is amortized across all customers.
Annual Infra Cost Breakdown by Module
Module Component Annual Cost Includes
Module 01: Alignment CMS API Integration $500–1K API calls, OAuth auth
Database (Alignment Records) $2K Patient alignment history, consent
Monitoring & Logging $2K Error tracking, audit trail
Support Infrastructure $5–10K Incident response, customer support
MODULE 01 TOTAL $10–15K
Module 02: Capture HL7v2 Listener (MLLP) $5K Lab results ingestion
FHIR Endpoint $3K EHR observation pull, SMART auth
Lab Connectors (3–5 vendors) $8–12K Multiple lab network integrations
Database (Measure Storage) $3K Lab results, timestamps, status
Monitoring & Error Handling $3K Missing lab alerts, retry logic
MODULE 02 TOTAL $20–30K
Module 03: Prediction ML Model Training $15K Initial + monthly retraining
Feature Engineering Pipeline $10K Data prep, transformation
API Integrations (Wearables) $5K Fitbit, Apple Watch, Garmin, etc.
GPU Compute (Inference) $8K Weekly score runs on 50K patients
Monitoring & A/B Testing $5K Model drift detection, validation
MODULE 03 TOTAL $30–50K
Module 04: Substitute-Spend BCDA API Integration $5K OAuth, claims API
Real-time Ingestion $5K Daily batch processing
Rules Engine $3K 90% threshold logic, penalties
Alerting & Notifications $7K Email, SMS, in-app alerts
MODULE 04 TOTAL $15–25K
Module 05: Ledger Dashboard & Analytics $8K Real-time updates, visualizations
Data Aggregation Pipeline $5K Combine all modules
CMS Submission Tracking $3K Audit trail, reconciliation
Reporting & Exports $4K PDF, Excel, API exports
MODULE 05 TOTAL $10–20K
Cross-cutting (Monitoring, Security, Ops) $20–30K Observability, HIPAA, incident response
TOTAL ANNUAL INFRA COST $105–170K Per customer, all 5 modules

Economics per Customer

Metric Value Notes
Aligned Beneficiaries (Avg) 50,000 Midmarket digital health org
Platform PMPM $1.75 Per beneficiary per month
Annual Platform Revenue $1,050,000 $1.75 × 50K × 12
Success Fee (12%) $80,640 12% of incremental OAP
Total Year 1 Revenue $1,130,640 Platform + success fee
Infra Cost (OIX) $130,000 Average of $105–170K range
Gross Profit $1,000,640 88.5% gross margin
Payback Period ~45 days Cost recovered in 1.5 months
Customer Value by Role
CFO / Finance
Real-time Cash Forecasting
• Know OAP earned/at-risk/lost daily, not monthly
• Forecast accuracy ±2% (vs competitors ±20%)
• Budget with confidence ("We'll capture $12M of $15M")
• Negotiate contracts with payers backed by data
Chief Medical Officer
Proactive Care Management
• Know at-risk patients by week 2 (not week 50)
• Route to right intervention automatically
• Track cohort outcomes (62% attainment vs 45% baseline)
• Close-loop learning: measure intervention effectiveness
Revenue Cycle Manager
Payment Assurance
• Catch alignment errors before CMS
• Monitor measure capture deadlines daily
• Track compliance with CMS requirements
• Audit trail for every patient submission
Care Coordinator
Operational Efficiency
• Auto-generated lab orders (no manual entry)
• Patient risk scores (know who to prioritize)
• Real-time intervention tracking
• Less time on admin, more on care
Patient
Better Care Outcomes
• Early outreach (not crisis management)
• Coordinated care (no conflicting instructions)
• Progress tracking (transparency on outcomes)
• Matched interventions (right program for them)
Organization (Overall)
Revenue Protection & Growth
• Protect $10M from the $15M OAP pool
• Avoid $3.75M substitute-spend clawback
• Capture $1.5M from attainment lift
• Build sustainable, predictable revenue
Summary: OIX transforms the organization from "hoping for 45% attainment" to "executing toward 65% attainment." Each module removes a specific operational bottleneck. Together, they increase OAP capture from ~$12M (80%) to ~$14.2M (95%) on a $15M opportunity.