Mock Pricing Pilot

The 30-60 day "Shadow Savings" pilot allows you to quantify ROI from Direct Contracts before switching payment rails to Turquoise.

Overview

Instead of immediately routing claims through Turquoise's settlement engine, run a parallel "shadow" adjudication process. Compare Direct Contract pricing against your current network, measure savings, and decide to activate with confidence.

Your Current Flow                Shadow Flow (Turquoise)
         ↓                                ↓
    Claim arrives             Claim sent to Turquoise
         ↓                                ↓
    Process through     vs.   Adjudicate via Direct
    leased network            Contract rates
         ↓                                ↓
    Pay provider               Calculate savings
         ↓                                ↓
    Invoice member      (Turquoise calculates)
                               Parallel pricing

Three Touchpoints

Touchpoint 1: Nightly Batch Upload

Each evening, send processed claims to Turquoise for shadow adjudication:

#!/bin/bash
# daily-shadow-audit.sh

# 1. Extract today's paid claims
sqlite3 claims.db "
  SELECT * FROM claims
  WHERE status = 'paid'
  AND paid_date = date('now')
" > /tmp/daily_claims.csv

# 2. Convert to Fast FHIR format
python convert_csv_to_fhir.py /tmp/daily_claims.csv > /tmp/claims.ndjson

# 3. Submit for shadow pricing
curl -X POST \
  https://api.turquoise.health/tpa-api/v1/claims/shadow-audit \
  -H "X-API-Key: $TURQUOISE_API_KEY" \
  -H "Content-Type: application/x-ndjson" \
  --data-binary @/tmp/claims.ndjson

echo "Submitted $(wc -l < /tmp/claims.ndjson) claims for shadow adjudication"

Expected response:

{
  "batch_id": "SHADOW-20240310-001",
  "claims_received": 127,
  "status": "processing",
  "estimated_completion": "2024-03-11T06:00:00Z"
}

info

Shadow audits are free. Turquoise doesn't charge service fees or settlement costs during the pilot.

Touchpoint 2: Shadow Adjudication Results

Each morning, retrieve pricing comparison from the previous day:

#!/bin/bash
# retrieve-shadow-results.sh

BATCH_ID=$(cat /tmp/shadow_batch_id)

curl -X GET \
  https://api.turquoise.health/tpa-api/v1/shadow-audit/$BATCH_ID/results \
  -H "X-API-Key: $TURQUOISE_API_KEY" \
  -H "Accept: application/json" \
  > /tmp/shadow_results.json

# Parse and store results
python analyze_shadow_results.py /tmp/shadow_results.json

Response payload:

{
  "batch_id": "SHADOW-20240310-001",
  "completed_at": "2024-03-11T06:00:00Z",
  "claims_adjudicated": 127,
  "summary": {
    "total_claims_amount": 156700.00,
    "leased_network_amount": 156700.00,
    "direct_contract_amount": 142300.00,
    "savings": 14400.00,
    "savings_percent": 9.2
  },
  "by_procedure": [
    {
      "cpt_code": "43235",
      "description": "EGD",
      "count": 34,
      "leased_network_rate": 1400.00,
      "direct_contract_rate": 1200.00,
      "savings_per_claim": 200.00,
      "total_savings": 6800.00
    },
    {
      "cpt_code": "45378",
      "description": "Colonoscopy",
      "count": 28,
      "leased_network_rate": 1800.00,
      "direct_contract_rate": 1500.00,
      "savings_per_claim": 300.00,
      "total_savings": 8400.00
    }
  ],
  "claims": [
    {
      "claim_id": "CLM-001",
      "member_id": "MEM-ABC123",
      "cpt_code": "43235",
      "leased_network_price": 1400.00,
      "direct_contract_price": 1200.00,
      "savings": 200.00
    }
  ]
}

Touchpoint 3: Weekly ROI Dashboard

View aggregated savings and trends via the dashboard:

https://dashboard.turquoise.health/pilots/your-org-id/roi

Dashboard Shows:

• Daily savings curve (trending)
• Procedure category breakdown
• Network utilization (% claims eligible for Direct Contracts)
• Projected annual savings
• Provider participation rate
• Member satisfaction scores

Example ROI Report

{
  "pilot_start_date": "2024-02-10",
  "report_date": "2024-03-10",
  "days_elapsed": 29,
  "projected_annual_savings": 525600.00,
  "summary": {
    "total_claims_submitted": 3721,
    "claims_with_direct_contracts": 1847,
    "contract_eligible_percent": 49.6,
    "average_savings_per_claim": 7.71,
    "cumulative_savings": 14229.87,
    "roi_multiplier": 18.5
  },
  "top_savings_procedures": [
    {
      "cpt": "45378",
      "description": "Colonoscopy",
      "claims": 412,
      "savings_percent": 22.5,
      "total_savings": 4157.00
    },
    {
      "cpt": "43235",
      "description": "EGD",
      "claims": 378,
      "savings_percent": 19.2,
      "total_savings": 3648.00
    }
  ],
  "network_impact": {
    "in_network_percent": 85.3,
    "facilities_activated": 12,
    "providers_activated": 47,
    "geographic_coverage": ["CA", "AZ", "NV"]
  },
  "member_impact": {
    "members_eligible": 28400,
    "members_received_savings": 2241,
    "average_member_savings": 6.35,
    "member_satisfaction_nps": 72
  }
}

Transition Plan: Batch → Real-Time API

Phase 1: Shadow Batch (Weeks 1-4)

• Continue current payment flow (no changes)
• Send nightly batch to Turquoise for shadow pricing
• Monitor savings in dashboard
• Cost to TPA: $0 (pilot period)

Phase 2: Pilot Activation (Weeks 5-6)

Once ROI is validated, route small percentage of eligible claims through Turquoise:

# Update routing logic
if claim.procedure_code in TURQUOISE_DIRECT_CONTRACTS:
    if random.random() < 0.10:  # Start with 10%
        submit_to_turquoise(claim)
    else:
        submit_to_leased_network(claim)

• Monitor real settlement flows
• Verify webhook delivery and reconciliation
• Start incurring Turquoise settlement fees (0.5% of claim amount)

Phase 3: Full Rollout (Week 7+)

Route all eligible claims through Turquoise:

if claim.procedure_code in TURQUOISE_DIRECT_CONTRACTS:
    submit_to_turquoise(claim)  # 100% of eligible claims
else:
    submit_to_leased_network(claim)

tip

Start with 10-25% of eligible claims, then scale gradually. This reduces operational risk and allows time for team training.

Key Success Metrics

Track these metrics during the pilot:

Metric	Target	Good Sign
Claims adjudicated daily	100+	200+
Direct contract eligibility	40%+	50%+
Savings per claim	$5+	$10+
Projected annual savings	$100K+	$250K+
Provider activation	5+	20+
Dashboard accuracy	±2%	±1%

Addressing Common Concerns

"Will this affect current payment flows?"

No. Shadow audits are purely observational. All payments continue through your current network for the duration of the pilot.

"How accurate is the pricing?"

Direct Contract rates are pulled from the same provider contracts Turquoise uses in production. Accuracy is 100% for contract lookups and 99.2% for adjudication (due to member eligibility differences).

"What if we decide not to activate?"

You can end the pilot anytime. Turquoise will delete all shadow audit data. No long-term commitments required.

"Can we test specific providers or procedures?"

Yes. Provide a list of CPT codes or provider NPIs, and Turquoise will prioritize those in the shadow audit.

Best Practices

Data Quality

Before submitting batch claims, validate:

def validate_claim(claim):
    assert claim.member_id, "Missing member_id"
    assert claim.provider_npi, "Missing provider_npi"
    assert claim.procedure_code, "Missing procedure_code"
    assert claim.service_date, "Missing service_date"
    assert claim.amount > 0, "Invalid amount"
    return True

Reconciliation Process

Each morning, reconcile shadow results to actual payments:

SELECT
  shadow.claim_id,
  shadow.direct_contract_price,
  actual.amount_paid,
  (actual.amount_paid - shadow.direct_contract_price) as variance
FROM shadow_results shadow
JOIN paid_claims actual ON shadow.claim_id = actual.id
WHERE ABS(variance) > 100  -- Flag large discrepancies

Regular Check-Ins

Schedule weekly reviews:

• Monday: Review prior week's shadow results
• Wednesday: Validate dashboard accuracy
• Friday: Plan upcoming week's focus areas

ROI Guarantee

If projected savings are under $50K annually after 4 weeks, Turquoise will provide additional contracts or credits to bridge the gap. No risk pilot.

warning

ROI projections assume 60%+ provider network participation. If participation is lower, savings may be reduced proportionally.

Graduation Criteria

Activate full Turquoise settlement when:

• ✓ Accumulated 4+ weeks of shadow data
• ✓ Projected annual savings exceed $100K
• ✓ Provider network activation ≥ 5 facilities
• ✓ Dashboard and API integration validated
• ✓ Internal stakeholders (Finance, Operations, Legal) approved

Next Steps

1. Request pilot enrollment: support@turquoise.health
2. Provide list of eligible procedure codes
3. Set up nightly batch export (see Touchpoint 1)
4. Monitor dashboard daily for first week
5. Schedule weekly ROI review meetings
6. Plan graduation timeline (target: 6 weeks)

Support

Dedicated pilot support team available via email or Slack:

• Daily updates on shadow audit processing
• Weekly ROI analysis and trend identification
• Provider and procedure recommendations
• Graduation planning assistance

Contact: pilots@turquoise.health