The patients your practices care for and the beneficiaries aligned to your ACO may be very different populations. In Mabel’s analysis of more than 100,000 fee-for-service lives across several ACO REACH organizations, only about 40% of eligible beneficiaries were claims-aligned.
Our findings point to a substantial opportunity within existing patient panels. Your ACO’s alignment gap will depend on its population and care patterns, but relying on claims alone can leave eligible care relationships unrecognized.
Voluntary alignment gives beneficiaries the means to identify their primary clinician directly.
For ACOs, it offers another route to recognizing those relationships, subject to CMS requirements. Understanding how these methods work together is the first step toward turning an alignment gap into a practical growth strategy.
Schedule a consultation with the Mabel team today to discover how our centralized campaign execution and tracking platform can strengthen your patient alignment strategy.
What Is Claims-Based Alignment?
Claims-based alignment uses Medicare claims to identify a beneficiary’s care relationship.
Broadly, CMS looks at the plurality of qualifying primary care services, measured by allowed charges under the applicable methodology. A plurality means the largest share; it does not necessarily mean a majority.
Claims record where care has been delivered, but they look backward. A new patient may already regard a clinician as their primary provider while the billing history has yet to catch up. One such delay could leave an established relationship in the examination room unrecognized in the alignment file, but scaled across an organization, it could amount to hundreds of unclear patient relationships.
Thus, claims-based alignment creates a foundation for an ACO’s population. Voluntary alignment complements that foundation by capturing the beneficiary’s stated choice.
What Is Voluntary Alignment?
Voluntary alignment allows a beneficiary to identify the clinician they consider their main source of care. ACO REACH and LEAD support two pathways:
- Medicare.gov Voluntary Alignment (MVA): The beneficiary identifies their primary clinician through Medicare.gov.
- Signed Voluntary Alignment (SVA): The beneficiary completes an attestation that the ACO collects and submits through the applicable CMS process.
A designation must meet the model’s requirements before it results in alignment. Outreach should therefore help patients understand and express their own choice, while the ACO verifies eligibility and tracks the outcome.
Claims-Based vs. Voluntary Alignment at a Glance
| Claims-based alignment | Voluntary alignment | |
| Evidence used | Qualifying claims history | Beneficiary designation |
| How it happens | CMS applies its methodology | The beneficiary acts through Medicare.gov or an attestation |
| Operational focus | Accurate participant records and roster reconciliation | Outreach, response handling, validation, and reconciliation |
| Role in the strategy | Establishes alignment through recorded care patterns | Helps recognize eligible relationships claims have not captured |
Both methods require attention to the applicable program and performance year. This article focuses on ACO REACH and LEAD; MSSP has its own assignment requirements.
Why Your Patient Roster and Alignment File May Differ
The 40% finding gives ACO leaders a reason to examine their own data. It should not become an assumption that 60% of every practice’s panel is available for voluntary alignment.
Start by comparing your active Medicare patient roster with the latest CMS alignment file. An unmatched record could reflect a current patient relationship that warrants outreach. It could also reflect outdated information, duplicate records, an identifier mismatch, or a coverage or eligibility issue.
These differences matter when planning campaigns. Treating every unmatched record as an opportunity can inflate growth forecasts and send staff after patients who should have been excluded or resolved during review.
The useful question is: Which patients have an eligible, current care relationship that voluntary alignment could help recognize?
Answering that question produces a more credible outreach population and gives your team a clearer view of the work required.
What Changes Under LEAD?
For ACOs preparing for LEAD, alignment timing deserves a separate decision. Claims-based and voluntary alignment describe how beneficiaries align; prospective and hybrid describe when alignment occurs.
Under CMS’s LEAD methodology, hybrid alignment permits monthly voluntary additions. SVA information must reach CMS at least 45 days before the effective month. Eligibility and overlap restrictions still apply, so a new designation does not automatically transfer a beneficiary already aligned elsewhere.
Operationally, a monthly opportunity calls for a recurring process. Your team needs time to review responses, correct errors, prepare submissions, and reconcile results before starting the next cycle.
How to Close the Alignment Gap
1. Measure and Review Your Opportunity
Reconcile practice rosters with CMS alignment files, remove duplicates and inactive records, and investigate discrepancies. Separate records ready for outreach from those needing eligibility or data review.
Document the starting population so later reports can show how the campaign moved from potential opportunity to confirmed results.
2. Organize Outreach Around Recognizable Care Relationships
Group outreach by practice and provider. Ask practice staff to review the intended population and identify records that need attention.
Beneficiaries should recognize the clinician named in the communication and understand why they are being contacted. Give staff a clear explanation of voluntary alignment and a route for handling questions.
3. Coordinate Your Outreach Channels
Plan how direct mail, email, and in-clinic conversations will work together. Use available contact preferences and keep response records connected so teams can see when a patient has already replied.
Review results by practice and channel. This can help distinguish a contact-information problem from a need for clearer communication or additional staff support.
4. Validate Responses Before Submission
Build time into the workflow to check required information, resolve mismatches, and follow up on incomplete responses. Assign responsibility for exceptions so unresolved records do not accumulate between teams.
Keep a record of corrections and submission status. A returned form should be traceable through each stage of processing.
5. Report Confirmed Alignment
Track forms received, records validated, submissions sent, and CMS-confirmed additions separately. Each measures a different stage of the process.
Report net growth after accounting for losses from the aligned population, and retain effective dates when assessing the result. This gives leadership a more useful view than a count of signatures alone.
Mabel in Practice
Mabel reports that one ACO REACH customer increased aligned lives by more than 30% over one year after adopting its end-to-end voluntary alignment workflow. The engagement combined outreach, response processing, and alignment tracking.
That customer result is separate from the multi-ACO analysis cited at the beginning of this article. Together, they illustrate both the potential opportunity and the operational work involved in pursuing it.
Read the ACO REACH case study.
Find Out Where Your Alignment Process Can Improve
A useful alignment strategy starts with a clear view of your patient population and follows each eligible response through to its outcome.
Your bottleneck may be identifying candidates, reaching patients, processing forms, or reconciling results. Establishing where the process breaks down helps you decide what support will make the greatest difference.
Mabel supports voluntary alignment campaign execution, response processing, submission preparation, and tracking. Your team can build a repeatable process with visibility into what has been completed and what still needs attention.
Talk to Mabel about your alignment gap.
Frequently Asked Questions
Does the 40% finding apply to every ACO?
No. It comes from Mabel’s analysis of more than 100,000 fee-for-service lives across several ACO REACH organizations. Use it as a reason to measure your own population, rather than as a forecast for your ACO.
Does a signed form count as a new aligned beneficiary?
Not by itself. A signed form is one stage in the process. Track validation, submission, and CMS-confirmed alignment separately so campaign reporting reflects completed outcomes.
Should we contact everyone missing from our alignment file?
Review the unmatched population first. Some records may need correction or removal, while others require further eligibility and care-relationship review. A clean outreach list helps staff focus their effort and reduces unnecessary patient contact.
How should we measure campaign success?
Track both operational progress and confirmed results. Response rates, processing time, unresolved exceptions, and confirmed additions can reveal different problems. Assess net alignment growth against a documented starting point, with effective dates retained.
