Behavioral Health Rate Setting & CCO Cost Optimization

Operating in partnership with the Cornerstone Whole Healthcare Organization (C-WHO), we developed an advanced, algorithmic Rate Setting Calculator. This specialized compliance and finance tool is deployed across local government health divisions in Oregon, specifically serving Lincoln County Health & Human Services, the Benton County Health Department, and the Linn County Department of Health Services.

Unifying FQHC Financial Operations

For Federally Qualified Health Centers (FQHCs), determining exact operational costs is a complex challenge. The Rate Setting Calculator aggregates a wide range of variables, including:

• Operational and facility overhead costs
• Granular CPT (Current Procedural Terminology) code processing costs
• Staffing overhead, benefits, and local administrative variables

By resolving these variables, our system enables health authorities to calculate their true cost-of-service. This quantitative visibility empowers them to negotiate accurate, sustainable Per Member Per Month (PMPM) rates with their local Coordinated Care Organizations (CCOs).

"Providing transparency in rate setting allows county clinics to defend operational budgets and negotiate sustainable CCO contracts with empirical clarity."

Clinical Visibility & Performance Insights

Beyond high-level rate negotiations, the Rate Setting Calculator provides health administrators with unparalleled internal visibility. The analytics dashboard compiles per-role CPT code usage and cross-references them against individual provider workflows.

This has allowed county health leadership to identify specific individuals and departments that are underperforming or operating below capacity. The system also models financial comparisons between Fee-For-Service (FFS) and Medicaid reimbursement structures, highlighting where operational changes are needed to prevent clinic deficits.

Future Expansion & Predictive Tools

Initially built to optimize behavioral health operations, the Rate Setting Calculator’s success has prompted plans for rapid expansion. County administrators are preparing to deploy the calculator across other FQHC divisions, including primary care, dental services, and community outreach teams.

To support this expansion, we are developing predictive modeling tools that simulate the financial impact of upcoming changes in Medicaid policy, provider turnover, and regional patient demographic shifts.