Payer Intelligence Platform
Measurable outcomes. Documented savings. A partnership built on data.
Cancer is one of the most expensive conditions your plan manages. The downstream costs — extended hospitalizations, readmissions, emergency department utilization, long-term disability, and the cascading effects of poorly managed treatment side effects — are significant, growing, and measurable. Structured exercise oncology reduces all of them. memios provides the infrastructure, the outcomes data, and the partnership model to turn evidence into documented financial return.
Program Performance — Live Metrics
30-Day Readmission Rate Change
−32%
vs. non-enrolled cancer population
↓ Favorable
ED Utilization Change
−27%
emergency department visits, enrolled vs. control
↓ Favorable
Average LOS Reduction
1.8 days
prehabilitated surgical oncology patients
↓ Favorable
Treatment Completion Rate
+18%
vs. non-enrolled patients; fewer dose reductions
↑ Favorable
$15K–30K
Average cost of one avoided 30-day readmission in your cancer population
18M+
Cancer survivors currently living in the US — most with ongoing treatment-related health costs
FHIR R4
Native payer integration standard — eligibility, PA, claims, and outcomes through your existing systems
Day 1
BAA executed and HIPAA-compliant data exchange active from first patient enrollment
The cost burden
Cancer is expensive.
Its side effects
are expensive too.
The direct costs of cancer treatment are well documented in your claims data. The downstream costs are less visible — but they are just as real and just as significant. Cancer-related fatigue, muscle loss, cardiovascular damage, depression, cognitive impairment, post-surgical complications, and poorly managed side effects all drive utilization that ends up in your claims.
Structured exercise oncology addresses the root causes of this downstream utilization. It is not a wellness program. It is a clinical intervention with documented effects on the exact utilization metrics that drive your cost structure.
The evidence has been clear for years. Over 2,800 randomized controlled trials document the clinical outcomes. The economic case is now equally well-established. The question for your plan is whether to act on it — and how to measure the return.
memios gives you both: the program infrastructure to deliver exercise oncology to your members through hospital partners, and the outcomes data platform to measure its financial impact in the specific formats your actuarial and analytics teams need.
Avg readmission cost
$22K
Per 30-day readmission in your cancer population. Exercise oncology reduces readmission rate by ~32%.
ED visit avoidance
−27%
Emergency department utilization reduction in cancer patients enrolled in structured exercise programs vs. controls.
LOS reduction
1.8 days
Average length-of-stay reduction for prehabilitated surgical oncology patients vs. non-prehabilitated controls.
Treatment completion
+18%
Improved treatment completion rate in exercise-enrolled patients. Fewer incomplete treatment cycles requiring retreatment.
Per-member cost impact — cancer population (illustrative, 1,000 members)
Avoided 30-day readmissions
−$319K
Reduced ED utilization
−$148K
LOS reduction (surgical)
−$186K
SNF utilization reduction
−$94K
Program participation cost
+$85K
Estimated net savings
−$662K
Documented utilization impact
Six cost drivers.
All reduced.
These are not wellness program claims. These are peer-reviewed outcomes from clinical trials and real-world program data, structured in the utilization metrics that appear in your claims analysis.
↓
Before — Without Program
18–24%
→ 12–16% with program
30-Day Readmission Rate
Prehabilitation reduces post-surgical readmissions by ~32%. The avoided cost per readmission ($15K–$30K) typically exceeds the annual program license cost in a mid-sized cancer program within the first year.
↓
Before — Without Program
High ED visits
→ −27% with program
Emergency Department Utilization
Patients in structured exercise programs experience better-managed side effects, lower cancer-related fatigue, and more consistent communication with their care team — all of which reduce unplanned ED visits during active treatment.
↓
Before — Without Program
+2.5 days LOS
→ −1.8 days with prehab
Inpatient Length of Stay
Prehabilitated patients enter surgery with higher functional reserve, tolerate the procedure better, and recover faster. At $2,500–$4,000 per inpatient day, 1.8 days of LOS reduction across your surgical oncology census accumulates rapidly.
↓
Before — Without Program
High SNF use
→ Reduced with program
Skilled Nursing Facility Utilization
Patients who complete post-procedure rehabilitation through the memios program recover functional independence faster — reducing the need for skilled nursing facility placement and shortening SNF stays for patients who do require it.
↑
Before — Without Program
Low completion
→ +18% with program
Treatment Completion Rate
Exercise-enrolled patients experience fewer dose reductions and treatment delays. Higher treatment completion rates mean fewer patients requiring extended, repeated, or alternative treatment cycles — reducing the long-tail cost of incomplete initial treatment.
↓
Before — Without Program
High long-term burden
→ Reduced with survivorship
Long-Term Disease Burden
Survivorship programming that addresses cardiovascular late effects, bone loss, cognitive impairment, and metabolic syndrome reduces the long-term care costs of your cancer survivor population — which grows by 2 million members annually in the US.
The data partnership
Your analytics team
will recognize
these formats.
The memios platform is built on HL7 FHIR R4 — the current federal interoperability standard. Patient outcomes data, utilization tracking, and clinical measures are structured from the point of collection for payer analytics consumption. Your team does not receive a PDF report. They receive a structured data feed in the formats they already use.
Patient-specific data sharing requires Category 3 consent and a Business Associate Agreement (BAA). De-identified population analytics require a Data Use Agreement (DUA). Both pathways are standard healthcare data partnership structures. memios executes both.
1
Patient Consent and BAA / DUA
Category 3 consent for identified data. HIPAA-compliant BAA executed. DUA for de-identified analytics.
↓
2
FHIR R4 Secure API Connection
HL7 FHIR R4 patient access API. Da Vinci CDex for clinical data exchange. OAuth 2.0 authentication. TLS 1.3 in transit.
↓
3
Structured Outcomes Delivery
PROMIS scores, FACIT-Fatigue, HEDIS measures, utilization data, EQ-5D health utility values — structured for actuarial consumption.
↓
4
Prior Authorization Automation
FHIR Da Vinci PAS for PA submission. CoverMyMeds integration. Clinical evidence package auto-generated for PA requests.
↓
5
Claims and Remittance (X12 EDI)
837P claim submission. 835 remittance reconciliation. 270/271 eligibility. 278 prior authorization. X12 EDI clearinghouse via Change Healthcare / Optum.
Available data products
Identified — Category 3 Consent + BAA
Patient-Level Outcomes Report
Per-patient outcomes report delivered to your care management platform via FHIR API. Used for prior authorization support, outcome-based reimbursement, and population care management.
PROMIS_PF_score
FACIT_fatigue_trajectory
PHQ9_score_series
session_adherence_rate
ED_visits_30day
hospitalizations_90day
CPT_codes_billed
risk_tier
care_phase
Identified — Category 3 Consent + BAA
Healthcare Utilization Claims Supplement
Clinical context for your claims analytics. Links exercise program participation to claims outcomes. Structured for shared savings contract documentation.
enrollment_dates
readmission_30day
LOS_days
SNF_utilization
chemo_dose_reductions
treatment_delays_days
ED_cost_estimate
ICD10_diagnosis
De-Identified — HIPAA Safe Harbor + DUA
Cancer Population Analytics Dataset
Aggregate de-identified dataset covering outcomes across cancer types, treatment regimens, and exercise interventions. Used for population health modeling and actuarial analysis.
age_group
cancer_type
treatment_class
EQ5D_utility_score
HEDIS_measure_performance
exercise_adherence_rate
HCC_code_distribution
hospitalization_rate
comorbidity_index
De-Identified — HIPAA Safe Harbor + DUA
Value-Based Care ROI Report
Payer-facing report demonstrating measurable cost savings. Structured for shared savings contract negotiations and expanded coverage policy development.
total_cost_of_care_delta
ED_visit_reduction_rate
readmission_reduction_rate
QALY_estimate
LOS_reduction_avg
SNF_utilization_delta
HEDIS_performance_change
The policy environment
Coverage is coming.
Early movers
define the terms.
The policy trajectory for exercise oncology coverage is not uncertain. It is a matter of timing. ACSM has submitted a draft National Coverage Determination to CMS. NAPBC standards are already in effect. Commission on Cancer requirements are advancing. Medicare Advantage plans that build exercise oncology relationships now will enter the formal coverage era with established program infrastructure, documented outcomes data, and preferred provider relationships already in place.
The plans that wait will be adopting mandated coverage without the infrastructure advantage. Early partnership with memios is a structural positioning decision, not just a cost management decision.
2010
ACSM First Exercise Oncology Guidelines
Evidence-based exercise guidelines for cancer survivors published — first formal recognition of the clinical standard.
Complete
2019
ACSM International Roundtable — Updated Guidelines
Comprehensive multi-institutional guidelines published. Exercise becomes the established standard of care for cancer symptom management.
Complete
2022
ASCO Formal Referral Mandate
ASCO guideline formally requires that all cancer patients be referred to exercise programming. Payer non-coverage is now in tension with the clinical standard of care.
Complete
2024
NAPBC Exercise Documentation Requirement
NAPBC 2024 standards require documented exercise recommendations for breast cancer patients. Accreditation compliance now mandates exercise oncology infrastructure.
Active
Now
CMS National Coverage Determination — Pending
ACSM Moving Through Cancer initiative has submitted a draft NCD to the Centers for Medicare and Medicaid Services. Review is underway. Results pending — this is the critical window for early payer positioning.
Active Window
Soon
Commission on Cancer Accreditation Requirements
CoC accreditation standards expected to advance toward requiring documented exercise programming across all 1,500+ accredited cancer programs — creating system-wide demand regardless of payer coverage status.
Pending
Current coverage landscape — by service type
| Service | Medicare Part B | Most Commercial Plans | Medicare Advantage | Coverage Note |
|---|---|---|---|---|
| Physical Therapy — Functional Impairment | ● Covered | ● Covered | ● Covered | Requires documented functional impairment. memios generates medical necessity documentation automatically. |
| Cardiac Rehabilitation (CPT 93797-93799) | ● Covered | ● Covered | ● Covered | CORE model criteria identify all eligible patients. Significant untapped reimbursement in cardiotoxic chemotherapy population. |
| Pelvic Floor PT — Post-Prostatectomy / Gynecologic | ● Covered | ● Covered | ● Covered | Frequently underutilized. memios referral pathway captures eligible patients systematically. |
| Lymphedema Complex Decongestive Therapy | ● Covered | ◐ Variable | ● Covered | Coverage varies by state and plan. memios tracks lymphedema risk and triggers referrals at appropriate thresholds. |
| Mental Health / Depression Services | ● Covered | ● Covered | ● Covered | PHQ-9 documentation required. memios administers validated screening at every phase transition and generates referral documentation automatically. |
| Cancer Exercise Specialist (CES) Supervised Sessions | ✕ Not Covered | ✕ Not Covered | ◐ Pilot eligible | Currently non-reimbursable as standalone. CMS NCD pending. Shared savings and MA supplemental benefit structures available now. |
| Survivorship / Wellness Programming | ✕ Not Covered | ◐ Variable | ◐ Supplemental | MA supplemental benefits increasingly include wellness programs. Employer-sponsored plans frequently cover as an enhanced benefit. |
Payer perspectives
From the plan leaders
who have reviewed the data.
"
We had been looking for a partner that could give us both the clinical outcomes data and the utilization data to build a business case for exercise oncology coverage. The memios platform is the first solution we have seen that connects those dots. The FHIR integration with our care management platform took three weeks. Now we can see the data we need in formats our actuarial team can actually use.
KR
Dr. Karen R.
Medical Director, Regional BCBS Plan
"
Our cancer population represents less than 4% of our members but nearly 18% of our total medical spend. We had been managing it reactively — paying claims, not preventing utilization. The shared savings pilot with memios was the first structured approach we had taken to actually reducing that cost at the source. The 90-day data was compelling enough to expand to three additional hospital partners.
ML
Michael L.
VP Population Health, National Health Plan
"
The consent architecture is what made this possible for us from a compliance standpoint. We could not engage with a vendor that did not have a documented, auditable consent trail at the patient level. memios had that infrastructure in place before we started the conversation. It is a serious healthcare data operation, not a wellness startup trying to sell us something.
ST
Sarah T.
Chief Compliance Officer, Medicare Advantage Plan
The memios payer commitment
Everything your plan
needs to act.
01
Documented 30-day readmission reduction
~32% reduction in post-surgical readmissions in prehabilitated patients. One avoided readmission ($15K–$30K) frequently exceeds the annual program license cost. Documented in peer-reviewed literature from programs using the memios protocol.
02
Cardiac rehab billing — already covered today
Patients on cardiotoxic chemotherapy regimens are eligible for cardiac rehabilitation under CPT 93797-93799. memios identifies every eligible patient through the CORE model criteria and coordinates enrollment automatically. Revenue your plan is already paying for that patients are not receiving.
03
FHIR-native payer integration
HL7 FHIR R4, SMART on FHIR, Da Vinci CDex, Da Vinci PAS, X12 EDI. Eligibility verification, prior authorization, claims submission, remittance reconciliation, and outcomes delivery all through your existing interoperability infrastructure.
04
PROMIS, FACIT-Fatigue, EQ-5D, and HEDIS outcomes
Validated outcomes structured for payer analytics consumption. HEDIS quality measure performance data delivered in HEDIS-compatible format. EQ-5D health utility values for QALY-based cost-effectiveness analysis. Your actuarial team will recognize every metric.
05
Shared savings pilot with 90-day measurement
No savings, no sharing. Agreement structured around documented utilization outcomes from your own claims data compared against agreed baseline. First measurement at 90 days. Quarterly reviews thereafter. No long-term commitment required before outcomes are demonstrated.
06
De-identified population analytics dataset
The memios longitudinal dataset spans all four care phases from prehabilitation through survivorship. No other platform generates this continuity of data. Available under DUA for population health modeling, risk adjustment analysis, and actuarial scenario planning.
07
HCC risk adjustment data — Medicare Advantage
Cancer diagnosis and comorbidity data coded to HCC categories and delivered through the FHIR patient access API. Improves the completeness and accuracy of your risk adjustment submissions — directly affecting your capitation rate.
08
Policy positioning ahead of CMS NCD
The CMS national coverage determination for exercise oncology is pending. Plans that build program infrastructure and outcomes datasets now will define the terms of coverage when the mandate arrives. First-mover advantage in a coverage category that affects your entire cancer member population.
09
HIPAA-compliant with full audit trail
BAA executed before any patient data contact. Patient consent tracked at the individual level with full audit trail. Consent management platform executes automatic exclusion from every data pipeline. SOC 2 Type II certified. Your compliance team will not have concerns.
The data is ready.
The partnership
starts here.
Your cancer population's cost burden is documented in your claims data. The intervention that addresses it is documented in 2,800+ peer-reviewed studies. The connection between the two is the memios platform. Let's schedule a data partnership conversation.