Medicaid Member Reconciliation · Before January 1, 2027
The Patients you manage in your System.The Members the Health Plan has assigned to your System.
FHG converts the Plan’s claims data into a reconciliation asset for your System — Member by Member, monthly. No EHR access required. This belongs on your monthly financial dashboard.
Rev Cycle 1.0 wasn’t built for this. Build the skill and develop the muscle memory to manage these shifts — before OBBBA doubles every gap on January 1, 2027. Four weeks to your first FHG baseline.
All Plan Segments
Inside the oval: the 285,000 Patients in your EHR. Outside-oval hatched: Members the Plan assigned to your roster, not yet in your EHR. Inner orange: Patients in your EHR who are insured by this Plan — but assigned to a competitor’s roster, not yours.
What FHG sees · Natively bilingual
Patients you manage that the Plan has assigned to your roster. Patients the Plan has assigned to your roster — that you’ve never seen. Patients you manage today — that the Plan has assigned to a competitor’s roster instead.
We deliver good care to our health plan’s Members; our competitor benefits because the plan has assigned our Patients to our competitor’s list.
— Health System Chief Medical Officer, observing the bidirectional reconciliation gap
What FHG makes operational today
Plan mistakes FHG surfaces today
The Pond · Rolling 12
Total Member
Months
457,503
Rolling 12
Members
Eligible
62,438
Rolling 12
Members
with Claims
52,614
Rolling 12
The denominator is small. The reconciliation is what makes it actionable. Every Member, every month — already operational today.After 1/1/27: every cycle compresses to 26 weeks. The same Pond is reconciled twice a year.
Population to track · PCP Panel Reconciliation
How do you manage risk and uncertainty when tens of millions in claims charges flows through Members you’ve never seen? This belongs on your monthly financial dashboard.
↓ click any node to drill into Members
Source · Data Ingestion 1 — Member ReconciliationToday: 29,403 Members at $1.1B, 100% unmanaged. After the storm: PCP continuity breaks faster — the residual grows.
Population to track · Geographic Reach
Cape Cod, the Berkshires, the far reaches of the state. In-network on paper. Unreachable in practice. $21.0M in unmanaged charges — monthly tracking required.
↓ click any node to drill into Members
Level 1 · Roster Denominator
FHG starts with every Member who generated claims activity in Rolling 12.
24,939 Members on this regional payor demo.
Level 2 · Claims-vs-Roster Split
Split by whether claims data shows where the Member actually lives.
20,008 generated claims with addresses; 4,931 are on the roster but produced no claims at all.
Level 3 · Hours From Care
1,119 Members in-state but hours from any in-network PCP. In-network on paper. Unreachable in practice. $21.0M in unmanaged charges.
Today: a small but legible residual. After Jan 1, 2027: 6-month redetermination notices go to addresses hours from any in-network PCP — the residual doubles.
Source · Data Ingestion 2 — Zip Code EligibilityToday: 1,119 Members at $21.0M. After the storm: doubled.
Roster to clean · Ineligible PCPs
Long-departed. Specialty-only. NPIs that never worked at the TaxID. Members assigned to clinicians who can’t deliver care. FHG surfaces every one by name, NPI, activity, and charges.
↓ hover any row to see the narrative
Ineligible-Clinician mistake-type distribution · N = 207
| Clinician | NPI | Members | Activities | Total Charges | Specialty | Mistake reason |
|---|---|---|---|---|---|---|
| Prov 19021 | 1528063500 | 400 | 1,845 | $1,641,533 | Primary Care | Departed 2024 |
| Prov 3798 | 1104388644 | 104 | 612 | $985,233 | Cardiology | Not PCP-able |
| Prov 11240 | 1294560011 | 247 | 1,103 | $722,109 | Primary Care | Never at TaxID |
| Prov 8821 | 1098765432 | 312 | 1,544 | $1,123,901 | Primary Care | Departed 2021 |
| Prov 22200 | 1609890250 | 879 | 3,859 | $1,489,071 | Family Med | Off-network 2023 |
Source · Data Ingestion 3 — Provider Database ReconciliationHighlighted row narrated by client. Today: 207 ineligible clinicians on this regional demo. After the storm: the cleanup runs every six months.
Cadence to track · Member Volatility
Adds. Drops. Net. FHG tracks every Member transition month over month — the kind of detail Rev Cycle 1.0 averages away.
↓ hover any month for the numbers · flip Storm mode to see the cadence change
Source · Data Ingestion 1 — Eligibility HistoryToday: Nov / Dec outliers under continuous enrollment. After the storm: every month is an outlier.
Convert claims data into your System’s asset.
Find your Patients. Track their Members.
Talk with FHGSibling Use Cases
Plan understands its network· Plan monitors redetermination· System monitors redetermination· ACO monitors shift & movement of at-risk lives· Monthly Member Reconciliation
Member-level drilldown
Level 1 · Eligible Denominator
FHG starts with every Member on plan eligibility in Rolling 12.
85,718 Members on this regional payor demo — the reconciliation universe.
Level 2 · PCP-Assignment Split
Split by whether the plan put a PCP on the eligibility record.
61,197 have a PCP assigned; 24,521 do not — no clinical relationship anchor on the roster at all.
Level 3 · 100% Unmanaged
29,403 Members had a PCP assigned but never saw them. $1.1B in claims charges — 100% unmanaged. No clinical anchor on the roster.
Today: $1.1B in charges, out of sight. After Jan 1, 2027: 6-month redetermination cycles break PCP continuity faster — every reset grows this column.