PROPOSED MEDICARE SHARED SAVINGS (ACO) PROGRAM RULES
|
|
- Liliana Carpenter
- 8 years ago
- Views:
Transcription
1 PROPOSED MEDICARE SHARED SAVINGS (ACO) PROGRAM RULES The Centers for Medicare and Medicaid Services (CMS) and other affected agencies released their notice of proposed rulemaking/request for comment for the Medicare Shared Savings Program (Program) on March 31, Although the program seeks to begin transforming the current fee-forservice delivery system, its initial scope and magnitude may not correspond with the exceedingly high level of attention paid to the concept of ACOs both prior to and since the release of the proposed rule for the reasons indicated below. REGULATORY IMPACT ANALYSIS CMS, in its regulatory impact analysis of the proposed rule, indicates there is substantial uncertainty as to the number of ACOs that will participate in the program, their characteristics, provider and supplier response to the financial incentives offered by the Program, and the ultimate effectiveness of the changes in care delivery that may result as ACOs work to improve the quality and efficiency of patient care. Under the proposed rule, ACOs would be required to commit to a three-year participation agreement with CMS. The median estimate of net savings of the Program for the three year term is $510 million. This projection assumes assignment of roughly 1.5 to 4 million Medicare beneficiaries to participating ACOs during the same period. Bearing on this estimate is that participation by patients (and providers) in ACOs is purely voluntary. Although CMS in its request for information on certain aspects of the program in November 2010 seemed to focus on the inclusion of smaller practices that may have limited access to capital or other resources to fund their ACO efforts, in the proposed rule, CMS estimated that only 75 to 150 ACOs might sign up to participate. As to capitalization, CMS roughly estimates based on Government Accountability Organization (GAO) findings of the Physician Group Practice (PGP) demonstration program start up investment and first year operating expenditures for a participant in the Program at $1.76 million. CMS, assuming ACOs, indicates an aggregate cost for ACO start up investment and first year operating expenditures in the range of $132 to $263 million. Not only on size, but also other factors, CMS has in large part, modeled the Program on the PGP demonstration. The PGP demonstration began in 2005 and was the first pay-for-performance initiative for physician groups in the Medicare program. The 10 groups in that demonstration were considered large as compared to other practices in terms of both annual medical revenue, non-physician and physician staff with each group at 200 or more physicians. Nine of the 10 groups were part of an integrated delivery system, 8 affiliated with a general hospital and 5 affiliated with an entity that marketed a health insurance product giving them greater access to relatively large amounts of financial capital needed to initiate or expand programs. A GAO analysis of the first year total operating expenditures for PGP participants varied greatly from $435,000 to $2.92 million, with the average for a group at $1.2 million. These costs included investments in infrastructure and information technology enhancements, management, quality reporting, and focused care coordination program. GAO also discovered that start up investment expenditures in the PGP demonstration varied between $82,600 and $ with the average group at $489,000. In addition to greater access to capital, the PGP
2 groups, due to their size and affiliations, had an increased probability of having or acquiring electronic health records (EHR) system which were essential to their ability to gather data and track progress in meeting quality of care targets. Eight of 10 groups had an EHR in place before the demonstration began, and the 2 others, out of necessity, developed alternative methods for gathering patient data electronically. A third size related advantage was their experience with other pay-for-performance systems both in public and private sectors prior to their participation in the demonstration. ACO RULE KEY PROVISIONS ACO Defined: An ACO is a legal entity that is recognized and authorized under applicable state law comprised of an eligible group of participants that work together to manage and coordinate care for Medicare fee-forservice beneficiaries and have established a mechanism for shared governance for all ACO participants with an appropriate proportionate control over the ACO s decision making process. Eligibility for Participation: The following groups of providers of services and suppliers are eligible to participate under the Program: ACO professionals (physicians, physician assistants, nurse practitioners, and clinical nurse specialists) in group practice arrangements, networks of individual practices of ACO professionals, partnership or joint venture arrangements between hospitals and ACO professionals, hospitals employing ACO professionals, and certain critical access hospitals. Governance: CMS proposes that (a) ACO participants have at least 75% of the control of the ACO s governing body; (b) clinical management and oversight is managed by a senior level medical director who is a boardcertified physician, licensed in the State in which the ACO operates, and physically present in that State; and (c) the ACO has a physician-directed quality assurance and process improvement committee. In addition, each ACO participant must choose an appropriate representative from within its organization to represent them on the governing body. ACOs must also have a formal legal structure in place for receiving and disbursing shared savings and capacity to accept a minimum of 5,000 assigned Medicare beneficiaries. The proposed rule does not require ACOs to be formed as separate legal entities. It does, though, solicit comment on whether requiring ACOs to be distinct legal entities would create a disincentive to ACO formation. Assignment of Beneficiaries: CMS proposes that beneficiaries be assigned (or aligned as CMS prefers to call it) based on whether they receive a plurality of their primary care services from ACO participating providers. Assignment in no way implies limitation, restriction or diminishment of Medicare beneficiaries under the Program to exercise complete freedom of choice in the physicians and other health care practitioners and suppliers from whom they receive their services. CMS adopted a retrospective approach to assignment meaning that assignment is based on historic claims data rather than prospective selection of the ACO by the beneficiary. Since assignment is College of American Pathologists Page 2
3 retrospective, ACOs would be required to inform beneficiaries of their participation in the shared savings program. ACOs will have an opportunity to request and receive CMS claims data (Medicare Part A, B, and D) on their assigned beneficiary population to facilitate their management of beneficiary care accessed both inside and outside the ACO. Receipt of any beneficiary identifiable claims data is conditioned on the ACO having entered into a Data Use Agreement with CMS. ACOs must inform beneficiaries of their ability to request data and provide them with an opportunity to opt-out of CMS s sharing their information with the ACO. Definition of Primary Care Services: Under the Program, physicians designated as primary care providers (PCPs) are those who practice in internal medicine, general practice, family practice and geriatric medicine. While PCP participation is limited to one ACO, specialists may participate with multiple. Promotion of Evidence-Based Medicine, Patient Engagement, Reporting, and Coordination of Care: Generally: CMS opted to simply require documentation of an ACO s plan to define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care rather than identifying specific criteria the ACO would be required to meet. CMS, though, will provide further guidance on how ACOs can satisfy these elements. ACO s quality performance scores would be subject to public reporting. In the instances where an ACO fails to meet the minimum attainment level for one or more quality domains indicated below, CMS proposes to give the ACO a warning and to reevaluate the following year. If the ACO continues to underperform the next year, CMS proposes to terminate the ACO from the Program. Quality Domains and PQRS/Other Measures: CMS proposes to use 65 quality measures and to publish specifications for the measures some time before the Program start date. These 65 measures span five quality domains: patient experience of care, care coordination, patient safety, preventive health, at-risk population/frail elderly health. Thirty of the measures are CMS Physician Quality Reporting System (PQRS) measures; 28 are new measures either National Quality Forum (NQF) endorsed and/or CMS adopted; 26 are from the EHR Meaningful Use program, and there is one measure incorporating the nine hospital acquired conditions. College of American Pathologists Page 3
4 In the first year of the Program, ACOs are required to report on the 65 measures for purposes of informing quality benchmarks, but reported data will only be used to evaluate performance in years 2 and 3. ACOs that fulfill the reporting requirement in year 1 will be deemed to have met the quality performance standard if they report on the required quality measures. Alignment with Meaningful Use (MU) EHR Requirements: CMS also is working, as mandated by the Affordable Care Act (ACA), to align the measures under the Program with those of the MU EHR incentive program overall. Consistent with this alignment, CMS proposes that as of year 2 of the ACO agreement that at least 50% of an ACO s PCPs would be required to be meaningful users of EHR. Patient Centeredness Criteria: CMS proposed a list of patient-centeredness principles that ACOs should integrate into their models and specific requirements for four elements of the criteria. Amongst the specific elements, CMS offers that ACOs should submit with their applications is an individualized care program for specific populations and description of their processes for evaluating the health needs of their Medicare populations. Shared Savings Models: CMS offers ACOs the option of participating in one of two models: 1. A one-sided shared savings model in which the ACO shares in any savings in years 1 and 2, but in year 3, is responsible for a portion of any losses it generates beyond a benchmark expenditure; and 2. A two-sided risk model in which the ACO is eligible for a larger percentage of shared savings, but in exchange, is also responsible for losses from day 1. ACOs are only eligible for shared savings payments if they first meet quality thresholds for all proposed measures standards in each domain indicated in the Process for Promotion of Evidence-Based Medicine, Patient Engagement, Reporting and Coordination of Care section above. If they do not achieve the quality thresholds requirements, they are not eligible for incentive payments even if they generate savings under the Program. CMS believes that acceptance of downside risk will provide stronger incentives than a shared savings only approach while the shared fee-for-service savings, even with optional liability for a portion of excess expenditures, offers some incentive for efficiency, but far less than other models such as full capitation. To determine shared savings for the ACO, CMS proposed an expenditure benchmark derived from expenditures under the Medicare fee-for-service program for beneficiaries who would have been assigned to the ACO in each of the three years prior to the Program be established and growthadjusted throughout the three year term. The amount of shared savings depends on a minimum savings rate (MSR) and sharing rates based on whether the ACO has selected a one-sided or two-sided approach and its number of assigned beneficiaries. The benchmark also includes adjustments for beneficiary characteristics including health status and demographics to more accurately predict health care expenditures to account for variations in case complexity and severity. In terms of repayment of losses, for track 2 ACOs, losses would need to exceed two percent of the ACO s benchmark before triggering repayment to CMS. For Track 1, repayment is capped at 5% in year 3 as this is the 1 st and only year in which they would face two-sided risk. College of American Pathologists Page 4
5 To protect the Medicare program against losses and ensure an adequate repayment mechanism under either the 1 or 2 sided risk models, CMS proposes a flat 25% withholding rate applied annually to any earned performance payment. For track 2 ACOs, the withhold may be not be adequate to cover shared losses, CMS has proposed repayment mechanisms including, but not limited to the following: recoupment from Medicare funds to ACO participating providers, reinsurance, placing funds in escrow, obtaining surety bonds. Losses that cannot be recouped in a given year would be carried forward until repaid. An ACO which experiences a net loss during the three-year period may not reapply. This is to ensure that under-performing ACOS do not continue to increase Medicare expenditure growth. CMS/OIG WAIVER DESIGNS FRAUD AND ABUSE LAWS CMS and OIG did not develop a proposed rule, but published notice and requested comments on waiver designs. Under ACA, the Health and Human Services Secretary was granted the authority to waive certain fraud and abuse laws (self-referral, anti-kickback, and gain-sharing civil monetary penalty (CMP) laws). The gain-sharing CMP law addresses hospital payments to physicians to reduce or limit services. The intent of the waivers is to avoid inhibiting ACO formation or operation. CMS expects to issue waivers concurrently with publication of the final regulations. Self-Referral/Anti-Kickback: CMS and OIG proposed that the Secretary waive application of the self-referral and anti-kickback laws to distributions of shared savings received by an ACO: (1) to or among those who were ACO participants during the year in which shared savings were earned; or (2) for activities necessary for and directly related to the ACO s participation in and operations under the Medicare shared savings program. The waiver is limited to distributions of shared savings. All other financial relationships or entities participating under the Program that would implicate the physician self-referral law would still need to satisfy an existing exception or safe harbor. Under the anti-kickback waiver, in addition to the above, CMS and OIG protect those financial relationships between and among the ACO and its participants that relate closely to ACO operations, but only if the relationship implicates the physician self-referral law and fits squarely in an exception. Ordinarily, arrangements that comply with the self-referral law are still subject to scrutiny under the antikickback statute. CMS and OIG are also interested in comments whether it should waive the self-referral law and antikickback statute for electronic health records donations scheduled to sunset at the end of Civil Monetary Penalties: Regarding CMPs, the proposal is that they be waived for: 1) distributions of shared savings from a hospital to physicians who were ACO participants during the year in which shared savings were earned provided that the payments are not made knowingly to induce the physician to reduce or limit medically necessary items or services and 2) any financial relationship between or among the ACO and its participants necessary for and directly related to the ACO s participation in and operations under the Medicare shared savings program that implicates the physician self-referral law and complies with an exception. College of American Pathologists Page 5
6 ANTITRUST ENFORCEMENT POLICY The Federal Trade Commission (FTC) and the Antitrust Division of the Department of Justice (DOJ) published their ACO Antitrust Policy Statement applicable to collaborations amongst otherwise independent providers and groups formed after the enactment date of the ACA on 5/23/2010, for notice and comment. The agencies created a safety zone for arrangements that are highly unlikely to raise significant competitive concerns. These arrangements do not need to seek FTC/DOJ approval. For an ACO to be in the safety zone, individual ACO participants that provide the same service (PSA) must have a combined share of 30% or less in their primary service area. To fall within the safety zone, hospitals and ambulatory surgery centers must be non-exclusive to the ACO. A rural exception was also created permitting participants to exceed 30% in their PSAs. Arrangements that exceed a 50% share of their PSA require mandatory review, but the agencies will perform an expedited 90 day review. Those arrangements below 50% and the 30% safety zone may seek review, but it is not required. The policy provides 5 types of conduct an ACO can avoid to significantly reduce the likelihood of an antitrust investigation. Rule of reason analysis rather than per se illegality under current antitrust law will be applied to arrangements that have qualified under the shared savings program to operate in the commercial rather than Medicare market. THE PROGRAM S IMPACT ON PATHOLOGISTS ACO Implementation/Governance: How many organizations that are not already formed as ACOs or integrated delivery systems will participate in the Program due to start up costs and operating expenses is not known. That said, pathologists are clearly eligible to participate in ACOs and have the opportunity to play a role in the leadership and management structure as the proposed governance structure is very provider-driven and local. Although the focus is on primary care, the proposed rule recognizes the ability to impact unnecessary repetition of laboratory testing. CMS permits ACOs to remove participants during the 3 year contract term, but not to add so timing is a significant consideration. Those who are not participants at the outset cannot be added until the end of the three year term if the ACO renews or enters into a new agreement with CMS under the Program. Quality Measurement: While none of the 65 measures proposed apply specifically to pathologists, many are heavily dependent on laboratory data necessitating ACO dependence on laboratories for this data to achieve their performance measures. Reliance on NQF measures is not ideal as to date, there are only 2 pathology measures that do not apply to all pathologists. 5 other measures are in queue, but the NQF process has been slow and overall, not terribly conducive to pathology measures development and approval. As far as alignment with MU measures is concerned, none of the Stage 1 MU measures are within pathologists usual scope of practice limiting pathologists ability to demonstrate their value. The College of American Pathologists Page 6
7 requirement that ACO participants be meaningful users by year 2 of the agreement is limited to primary care which is favorable, but could be problematic for pathologists if further MU alignment occurs in subsequent rulemakings. At the outset, the proposed rule relies on claims based measures linked to individual patients and providers which is not ideal for capturing the value of pathology on population health and care teams. CMS does acknowledge this problem, at least in part indicating that measures dealing with laboratory results are not conducive to claims-based reporting, since claims typically include diagnosis and procedure codes, but not specific test results. Patient-Centeredness: The patient-centeredness criteria, although somewhat vague at this point, may provide an opportunity for pathologists to contribute to assisting the ACO in the development of the required individualized care program for specific populations which could relate directly to personalized medicine. Shared Savings: The underlying reimbursement remains fee-for-service and provider participation is completely voluntary so there is little impact on providers regardless of whether they are ACO participants. If they are not participants, they lose the opportunity to earn potential savings, but on the flip side, are not responsible for any ACO losses. It remains to be seen whether the possible return on investment will be significant enough to motivate organizations to become Medicare ACOs. CMS proposes to require ACOs to report on any shared savings distributions, but does not believe it has the authority to specify how shared savings must be distributed so incentive payments to individual ACO participants will be a matter of local negotiation. CMS/OIG Waiver Designs Fraud and Abuse Laws: The waivers do not speak directly to the in office ancillary exception to the Stark law or specifically to self-referral of anatomic pathology services, but rather they focus on the distribution of shared savings. To the extent laboratories remain protected donors of EHRs, the extension of the scheduled 2013 sunset for EHR donation safe harbor under the anti-kickback statute would be inconsistent with CAP s longstanding position opposing such inclusion and objectionable. Historically, the gainsharing CMPs have looked at payments made to induce the physician to reduce or limit items or services. The proposed rule modifies this in the context of ACO distribution of shared savings from a hospital to physicians made to induce the physician to reduce or limit medically necessary items or services. Antitrust Enforcement Policy: While the policy is not specific to pathology, it provides clarity on certain antitrust specifics in the context of the ACO environment beyond what exists in current DOJ/FTC Statements of Antitrust Enforcement Policy in Health Care that precede the ACO concept. More specialty-specific, it also enlightens on the combined share of individual ACO participants providing the same service that will either fall within a newly proposed safety zone or will necessitate review by the agencies. College of American Pathologists Page 7
Additional Information About Accountable Care Organizations
Additional Information About Accountable Care Organizations For more information, please contact: April 2011 On March 31st, the federal government outlined proposed actions relating to Accountable Care
More informationDETAILED SUMMARY--MEDCIARE SHARED SAVINGS/ACCOUNTABLE CARE ORGANIZATION (ACO) PROGRAM
1 DETAILED SUMMARY--MEDCIARE SHARED SAVINGS/ACCOUNTABLE CARE ORGANIZATION (ACO) PROGRAM Definition of ACO General Concept An ACO refers to a group of physician and other healthcare providers and suppliers
More informationCMS Releases Proposed Rule Governing Accountable Care Organizations
CMS Releases Proposed Rule Governing Accountable Care Organizations Health Care Organizations Face Complex Strategic Decisions Authors: Robert D. Belfort Paul M. Campbell Susan R. Ingargiola Stephanie
More informationEntities eligible for ACO participation
On Oct. 20, 2011, the Centers for Medicare & Medicaid Services (CMS) finalized new rules under the Medicare Shared Savings Program (MSSP) to help doctors, hospitals, and other health care providers better
More informationGuidance Released on Accountable Care Organizations Participating in the Medicare Shared Savings Program
M A Y 2 0 1 1 Guidance Released on Accountable Care Organizations Participating in the Medicare Shared Savings Program On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), the Department
More informationMedicare ACO Road Map
PYALeadership Briefing Medicare ACO Road Map January, 2013 Medicare ACO Road Map The Centers for Medicare & Medicaid Services ( CMS ) has announced 106 new accountable care organizations ( ACOs ) have
More informationCMS ACO Proposed Regulations
CMS ACO Proposed Regulations May 2011 Proposed CMS ACO Regulations Proposed Regulations issued March 31, 2011 Comments due back June 6, 2011 Requires 3 year binding commitment Formal Legal Structure Required
More informationNATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS. Briefing Paper on the Proposed Medicare Shared Savings Program
NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS Briefing Paper on the Proposed Medicare Shared Savings Program The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to implement
More informationParticipating Accountable Care Organizations (ACOs) that meet quality performance standards will be eligible to receive payments for shared savings.
Background Sec. 3022 of the Patient Protection and Affordable Care Act (PPACA) requires the Secretary to establish the Medicare Shared Savings Program by Jan. 1, 2012 Program goals: Promote accountability
More informationAccountable Care Organizations (ACO) Proposed Rule Summary March 31, 2011
Accountable Care Organizations (ACO) Proposed Rule Summary March 31, 2011 On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS) released the longawaited proposed rule on Accountable Care
More informationNATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS. Briefing Paper on the Proposed Medicare Shared Savings Program
NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS Briefing Paper on the Proposed Medicare Shared Savings Program The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to implement
More informationThe true meaning of ACO is Awesome Consulting Opportunities. - The Weekly Standard, 04/12/11. Consultants
Accountable Care Organizations: Proposed Regulations and the Local Landscape May 26, 2011 John Clark, MD, JD Isaac M. Willett Medical Director, Clinical i l Informatics Attorney Indiana University Health
More informationII. SHARED SAVINGS PROGRAM AND COST-REDUCTION INCENTIVES
E-ALERT Health Care April 15, 2011 ACCOUNTABLE CARE ORGANIZATION BASICS The Affordable Care Act establishes the Medicare Shared Savings Program ( Program ), which provides for the development of accountable
More informationM E M O R A N D U M. CMS Proposed Rule & Related Agency Notices on Accountable Care Organizations
1501 M Street NW Seventh Floor Washington, DC 20005-1700 Tel: 202.466.6550 Fax: 202.785.1756 M E M O R A N D U M To: From: Clients and Friends Powers Pyles Sutter & Verville, PC Date: April 10, 2011 Re:
More informationA Closer Look at the Final ACO Rule
A Closer Look at the Final ACO Rule October 2011 For more information, please contact: On October 20th, the federal government released a final rule and other companion releases relating to Accountable
More informationSummary of Medicare Shared Savings Program Final Rule on Accountable Care Organizations
Summary of Medicare Shared Savings Program Final Rule on Accountable Care Organizations On November 2, 2011, the Centers for Medicare and Medicaid Services ( CMS ) published a Final Rule implementing the
More informationWho, What, When and How of ACOs. Summary of proposed rule provisions for Accountable Care Organizations under the Medicare Shared Savings Program
Who, What, When and How of ACOs Summary of proposed rule provisions for Accountable Care Organizations under the Medicare Shared Savings Program April 5, 2011 On March 31, 2011, the Centers for Medicare
More informationCms Finally speaks: organization (ACO) proposed regulations and WhaT They mean For anesthesiologists
ANESTHESIA BUSINESS CONSULTANTS SUMMER 2011 VOLUME 16, ISSUE 2 Cms Finally speaks: The accountable Care organization (ACO) proposed regulations and WhaT They mean For anesthesiologists Since the passage
More informationAccountable Care Organizations: The Final Rule
Accountable Care Organizations: The Final Rule October 27, 2011 2011 Akin Gump Strauss Hauer & Feld LLP 10.27.11 101799002 v4 Overview Background Final Rule Highlights Structure and Formation of ACOs Quality
More informationCMS proposed rule on ACOs: http://www.gpo.gov/fdsys/pkg/fr-2011-04-07/pdf/2011-7880.pdf
April 7, 2011 Dear Physician Colleague: On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS) issued its long awaited proposed regulations on the Medicare Shared Savings/Accountable Care
More informationClient Advisory. CMS Issues Final ACO Regulations EXECUTIVE SUMMARY. Health Care. Eligibility. November 10, 2011
Client Advisory Health Care November 10, 2011 CMS Issues Final ACO Regulations After receiving more than 1,300 public comments on its Proposed Rule for Accountable Care Organizations (ACOs) under the Medicare
More informationMedicare Accountable Care Organizations: What it s about
Medicare Accountable Care Organizations: What it s about Gail Albertson, MD Associate Professor of Medicine Chief Operating Officer, UPI Medicare Accountable Care Under the Medicare Shared Savings Program
More informationAccountable Care Organizations: What Providers Need to Know
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Accountable Care Organizations: FACT SHEET Overview http://www.cms.gov/sharedsavingsprogram On October 20, 2011, the Centers
More informationAccountable Care Organizations Multiple Comment Periods
Accountable Care Organizations Multiple Comment Periods Proposed Waivers CMS and OIG CMS and HHS Office of Inspector General (OIG) jointly issued a notice with comment period outlining proposals for waivers
More informationAccountable Care Organization Final Rule Briefing. November 7, 2011
Accountable Care Organization Final Rule Briefing November 7, 2011 Health Care Reform: Health Care Delivery Reforms GOALS: Controlling Cost Growth Improving Quality/Outcomes Changing Incentives Coordinating
More informationKATHLEEN L. DEBRUHL & ASSOCIATES, L.L.C. 614 TCHOUPITOULAS STREET NEW ORLEANS, LOUISIANA 70130 504.522.4054 (OFFICE) 504.522.9049 (FAX) WWW.MD-LAW.
CMS RELEASES PROPOSED ACCOUNTABLE CARE ORGANIZATION REGULATIONS By: Kathleen L. DeBruhl, Esq. and Lindsey E. Surratt, Esq. On March 31, 2011, the Centers for Medicare and Medicaid Services ( CMS ) issued
More informationMedicare Final Accountable Care Organization (ACO) Regulations Effective January 1, 2012 Median Savings of $470 Million over 4 Years
October 20, 2011 CIT Healthcare, John M. Cousins, SVP Healthcare Intelligence john.cousins@cit.com Tel: 850-668-2907 Cell: 716-867-9965 Medicare Final Accountable Care Organization (ACO) Regulations Effective
More informationMedicare Shared Savings Program: Accountable Care Organizations final rule Summary
Medicare Shared Savings Program: Accountable Care Organizations final rule Summary Table of Contents: Background.......1-2 Executive Summary......2-3 Medicare ACO Eligibility........3 Medicare ACO Structure
More informationOber Kaler ACO Update
October 27, 2011 Ober Kaler ACO Update CMS Provides Final Framework for ACO and Shared Savings Program Rules: ACO Participants Get Greater Flexibility CMS s final regulations (final rule) implementing
More informationIn early April, the Center for Medicare and Medicaid Services (CMS) issued
April 26, 2011 If you have any questions regarding the matters discussed in this memorandum, please contact the following attorneys or call your regular Skadden contact. John T. Bentivoglio 202.371.7560
More informationAmy K. Fehn. I. Overview of Accountable Care Organizations and the Medicare Shared Savings Program
IMPLEMENTING COMPLIANCE PROGRAMS FOR ACCOUNTABLE CARE ORGANIZATIONS Amy K. Fehn I. Overview of Accountable Care Organizations and the Medicare Shared Savings Program The Medicare Shared Savings Program
More informationPhysician Integration Models: ACOs as the Latest and Greatest? David T. Lewis david.lewis@lpnt.net LifePoint Hospitals, Inc.
Physician Integration Models: ACOs as the Latest and Greatest? David T. Lewis david.lewis@lpnt.net LifePoint Hospitals, Inc. Brentwood, TN Kim Harvey Looney kim.looney@wallerlaw.com Waller Lansden Dortch
More informationAccountable Care Organizations and Provider Integration Under Health Care Reform. Sarah Swank 202.326.5003 seswank@ober.com
Accountable Care Organizations and Provider Integration Under Health Care Reform Sarah Swank 202.326.5003 seswank@ober.com February 26, 2014 Overview Affordable Care Act and ACOs Trends in Integration
More informationAccountable Care Organizations: Experiences, Examples and Lessons Learned
Accountable Care Organizations: Experiences, Examples and Lessons Learned New York State Academy of Family Physicians Downstate Regional Family Medicine Conference Jeffrey R. Ruggiero Arnold & Porter LLP
More informationFraud and Abuse Considerations for Accountable Care Organizations (ACOs)
Fraud and Abuse Considerations for Accountable Care Organizations (ACOs) By: Chris Rossman, Foley & Lardner LLP, Detroit, Michigan 1. The Centers for Medicare and Medicaid Services ( CMS ) and the Office
More informationPROPOSED RULES FOR ACCOUNTABLE CARE ORGANIZATIONS PARTICIPATING IN THE MEDICARE SHARED SAVINGS PROGRAM: WHAT DO THEY SAY?
PROPOSED RULES FOR ACCOUNTABLE CARE ORGANIZATIONS PARTICIPATING IN THE MEDICARE SHARED SAVINGS PROGRAM: WHAT DO THEY SAY? The Affordable Care Act authorizes the Centers for Medicare and Medicaid Services
More informationHow Will the ACO Regulations Affect You?
How Will the ACO Regulations Affect You? Wednesday, June 1, 2011 Presented by: Michele Madison Partner, Healthcare & Healthcare IT Practices Ward Bondurant Partner, Healthcare, Insurance & Corporate Practices
More informationProvider Participation in ACOs May Hinge on HHS Regulations
Source: Health Law Reporter: News Archive > 2010 > 04/15/2010 > BNA Insights > Provider Participation in ACOs May Hinge on HHS Regulations Provider Participation in ACOs May Hinge on HHS Regulations 19
More informationAccountable Care Organizations
Building a Healthy ACO Compliance Program HCCA 2014 Compliance Institute Mary C. Malone, Esq. Hancock, Daniel, Johnson & Nagle, P.C. Disclaimer: The content of this presentation does not constitute legal
More informationFAQs on the final ACO regulations
- 1 - December 28, 2011 FAQs on the final ACO regulations By Peter A. Egan, Linn Foster Freedman, Carolyn J. Gabbay, Christopher P. Hampton, Lindsay Maleson, David A. Martland, Michele A. Masucci, Christopher
More informationStatement of the Association of American Medical Colleges on Legal Issues Related to Accountable Care Organizations and Healthcare Innovation Zones
Statement of the Association of American Medical Colleges on Legal Issues Related to Accountable Care Organizations and Healthcare Innovation Zones Public Workshop hosted by the FTC, CMS, HHS OIG October
More informationMedicare Shared Savings Program Final Rule
Healthcare Committee Medicare Shared Savings Program Final Rule On June 9, 2015, the Centers for Medicare & Medicaid Services ( CMS ) published a final rule that, according to the agency, will update and
More informationCOMMENTARY. HHS Announces Next Generation ACO Model of Payment and Care Delivery. Potential Participants. Focus of the Next Gen ACO Model
April 2015 COMMENTARY HHS Announces Next Generation ACO Model of Payment and Care Delivery On March 10, 2015, the U.S. Department of Health and Human Services ( HHS ) announced the Next Generation Accountable
More informationThe Medicare Shared Savings Program
The Medicare Shared Savings Program Centers for Medicare & Medicaid Services Jonathan Blum, Deputy Administrator & Director, Center for Medicare May 20, 2011 Overview CMS s vision of its ACO program Summary
More informationNewsroom. The quality measures are organized into four domains:
Newsroom People with Medicare will be able to benefit from a new program designed to encourage primary care doctors, specialists, hospitals, and other care providers to coordinate their care under a final
More informationHow To Track Spending On A Copay
Accountable Care Organizations & Other Reimbursement Reforms: The Impact on Physician Practices Martin Bienstock, Esq. Wilson Elser Martin.Bienstock@WilsonElser.com The New York Times Take... For the first
More informationMedicare Shared Savings Program
Medicare Shared Savings Program Shared Savings Program http://www.cms.gov/savingsprogram/ Centers for Medicare & Medicaid Services February 2012 Medicare Shared Savings Program (Shared Savings Program)
More informationAccountable Care Organizations: Importance to Physicians in Value Based Payment June 19, 2014 12:00-1:00pm EST
Accountable Care Organizations: Importance to Physicians in Value Based Payment June 19, 2014 12:00-1:00pm EST Ahmed Haque, Director of Care Transformation Health IT U.S. Department of Health & Human Services
More informationHEALTH REFORM LAW: ACCOUNTABLE CARE ORGANIZATIONS
HEALTH REFORM LAW: ACCOUNTABLE CARE ORGANIZATIONS PRESENTED AT THE NASABA 2011 CONVENTION BY: PURVI B. MANIAR Context and Background Patient Protection and Affordable Care Act of 2010 ( PPACA ) (Section
More informationThe Accountable Care Organization
The Accountable Care Organization Kim Harvey Looney kim.looney@ 615-850-8722 3968555 1 ACOs: Will I Know One When I See One? Relatively New Concept Derived from Various Demonstration Programs No Set Structure
More informationMar. 31, 2011 (202) 690-6145. Summary of proposed rule provisions for Accountable Care Organizations under the Medicare Shared Savings Program
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 Office of Media Affairs MEDICARE FACT SHEET FOR IMMEDIATE RELEASE
More informationIssue Brief. CMS Finalizes Rules for Medicare Shared Savings Program (ACOs) KEY POINTS COMMENT
Issue Brief 4712 Country Club Drive Jefferson City, MO 65109 P.O. Box 60 Jefferson City, MO 65102 573/893-3700 www.mhanet.com FEDERAL ISSUE BRIEF June 5, 2015 KEY POINTS z More than 400 accountable care
More informationG-2. Report. Compliance. An ambitious health reform subtitle, Transforming the Health
G-2 Kimberly Scott, Managing Editor, kscott@ioma.com Carrie Valiant is a senior member of the health care and life sciences practice of the national law firm, EpsteinBeckerGreen, practicing in its Washington,
More informationAccountable Care Organizations: Notice of Proposed Rulemaking
Accountable Care Organizations: Notice of Proposed Rulemaking Presentation by: Pam Silberman, JD, DrPH North Carolina Institute of Medicine April 15, 2011 1 Accountable Care Organizations (ACOs) An ACO
More informationOHIO HOSPITAL ASSOCIATION 2015 Annual Meeting. Accountable Care Organizations Comprehensive Integration Strategy
OHIO HOSPITAL ASSOCIATION 2015 Annual Meeting Accountable Care Organizations Comprehensive Integration Strategy ACO Development Market Conditions Increasing Economic pressures Consumerism Regulatory scrutiny
More informationLook Before You Leap: Legal and Practical Obstacles with ACOs
Look Before You Leap: Legal and Practical Obstacles with ACOs Houston ACO Conference May 7, 2013 Edward Vishnevetsky, Esq. Coordinated Care and ACOs Coordinated Care Goal: ensure that healthcare providers
More informationWhat keeps you up at night?
HEALTH PRACTICE GROUP APRIL 2011 Saul Ewing Health Practice Group: George W. Bodenger Chair What keeps you up at night? The ACO Proposed Rule: A Need to Know Summary By Karen Palestini SUMMARY On March
More informationUsing Partial Capitation as an Alternative to Shared Savings to Support Accountable Care Organizations in Medicare
December 2010 Using Partial Capitation as an Alternative to Shared Savings to Support Accountable Care Organizations in Medicare CONTENTS Background... 2 Problems with the Shared Savings Model... 2 How
More information2010 MHA Governance Leadership Forum: Accountable Care Organizations. Chris Rossman, Esq. Foley & Lardner LLP Detroit, Michigan
2010 MHA Governance Leadership Forum: Accountable Care Organizations Chris Rossman, Esq. Foley & Lardner LLP Detroit, Michigan Overview Major health care payment reform under the Affordable Care Act (
More informationSustainable Growth Rate (SGR) Repeal and Replace: Comparison of 2014 and 2015 Legislation
Sustainable Growth Rate (SGR) Repeal and Replace: Comparison of 2014 and 2015 Legislation Proposal 113 th Congress - - H.R.4015/S.2000 114 th Congress - - H.R.1470 SGR Repeal and Annual Updates General
More informationProposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program
Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program I. Introduction The Patient Protection and Affordable Care
More informationBrief Course. Neil Kirschner, Ph.D. Director, Regulatory and Insurer Affairs
Accountable Care Organization (ACO) 101 Brief Course Neil Kirschner, Ph.D. Director, Regulatory and Insurer Affairs What is an ACO? ACO refers to a legal entity composed of a group of providers that assume
More informationMedicare ACO Road Map
Medicare ACO Road Map SECOND EDITION APRIL 2014 No portion of this white paper may be used or duplicated by any person or entity for any purpose without the express written permission of PYA. With the
More informationTHE FINAL RULE FOR THE MEDICARE SHARED SAVINGS PROGRAM
THE FINAL RULE FOR THE MEDICARE SHARED SAVINGS PROGRAM The Affordable Care Act authorizes the Centers for Medicare and Medicaid Services (CMS) to establish a Medicare Shared Savings Program that would
More informationHealthcare Reform Update Conference Call VI
Healthcare Reform Update Conference Call VI Sponsored by the Healthcare Reform Educational Task Force October 9, 2009 2:00-2:45 2:45 pm Eastern Healthcare Delivery System Reform Provisions in America s
More informationMay 26, 2011. Section 3022 of the Affordable Care Act. Dear Administrator Berwick:
Donald M. Berwick, MD, MPP Administrator Attention: CMS-1345-P Mail Stop C4-26-05 7500 Security Boulevard Baltimore, MD 21244-1850 Re: Section 3022 of the Affordable Care Act Dear Administrator Berwick:
More informationBecoming an ACO The Rules and Requirements
Becoming an ACO The Rules and Requirements Drinker Biddle ACO Workgroup Webinar November 3, 2011 Speakers Matthew Amodeo, Partner Drinker Biddle & Reath LLP Albany, N.Y. Matthew.Amodeo@dbr.com (518) 862-7468
More informationDepartment of Health and Human Services. No. 209 October 29, 2015. Part III
Vol. 80 Thursday, No. 209 October 29, 2015 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Chapter IV Office of Inspector General 42 CFR Chapter V Medicare
More informationReforming and restructuring the health care delivery system
Reforming and restructuring the health care delivery system Are Accountable Care Organizations and bundling the solution? Prepared by: Dan Head, Principal, RSM US LLP dan.head@rsmus.com, +1 703 336 6536
More informationElise Smith, Vice President, Finance Policy William Hartung, Vice President, Research Sandra Fitzler, Senior Director, Clinical Services
Robert Van Dyk CHAIR Van Dyk Health Care Ridgewood, NJ Neil Pruitt, Jr. VICE CHAIR UHS-Pruitt Corporation Norcross, GA Rick Miller IMMEDIATE PAST CHAIR Avamere Health Services Wilsonville, OR Leonard Russ
More informationBAKER DONELSON BAKER S DOZEN
Thirteen Things Health Care Providers Should Know About Accountable Care Organizations and Health Reform Thomas E. Bartrum, 615.726.5641, tbartrum@bakerdonelson.com With passage of the Patient Protection
More informationCHAPTER 114. AN ACT establishing a Medicaid Accountable Care Organization Demonstration Project and supplementing Title 30 of the Revised Statutes.
CHAPTER 114 AN ACT establishing a Medicaid Accountable Care Organization Demonstration Project and supplementing Title 30 of the Revised Statutes. BE IT ENACTED by the Senate and General Assembly of the
More informationLarge Urology Group Practice Association. Accountable Care Organizations
Large Urology Group Practice Association Accountable Care Organizations November 6, 2010 J. Phillip O Brien 312.902.5630 phillip.obrien@kattenlaw.com Basic Premise for ACOs Facilitate medical care coordination
More informationMedicare Shared Savings Program: Accountable Care Organizations. Centers for Medicare and Medicaid Services Final Rule Provisions
Medicare Shared Savings Program: Accountable Care Organizations Centers for Medicare and Medicaid Services Final Rule Provisions The Centers for Medicare and Medicaid Services (CMS) published a final rule
More informationThe Regulations Are Out: Is An ACO Right For You? Moderator David Pursell 816.983.8190 david.pursell@huschblackwell.com
The Regulations Are Out: Is An ACO Right For You? Moderator David Pursell 816.983.8190 david.pursell@huschblackwell.com Today s Discussion Overview of the ACO Regulations Alternatives to a Medicare ACO
More informationDecember 3, 2010. Donald M. Berwick, M.D. Administrator Centers for Medicare and Medicaid Services Posted to Regulations.gov. File code CMS-1345-NC
December 3, 2010 Donald M. Berwick, M.D. Administrator Centers for Medicare and Medicaid Services Posted to Regulations.gov File code CMS-1345-NC Dear Dr. Berwick: The American Urological Association (AUA),
More informationSummary of Final Rule Provisions for Accountable Care Organizations under the Medicare Shared Savings Program
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Summary of Final Rule Provisions for Accountable Care Overview The Centers for Medicare & Medicaid Services (CMS), an agency
More informationCrosswalk: CMS Shared Savings Rules & NCQA ACO Accreditation Standards 12/1/2011
Crosswalk: CMS Shared Savings Rules & NCQA ACO Accreditation Standards 12/1/2011 The table below details areas where NCQA s ACO Accreditation standards overlap with the CMS Final Rule CMS Pioneer ACO CMS
More informationAre ACOs For You? Things You Should Know If You Are Considering Medicare Shared Savings Programs
1501 M Street, NW Seventh Floor Washington, DC 20005 Phone: (202) 466-6550 Fax: (202) 785-1756 www.ppsv.com Are ACOs For You? Things You Should Know If You Are Considering Medicare Shared Savings Programs
More informationFinalized Changes to the Medicare Shared Savings Program
Finalized Changes to the Medicare Shared Savings Program Background: On June 4, 2015, the Centers for Medicare and Medicaid (CMS) issued a final rule that updates implementing regulations for the Medicare
More informationCLINICALLY INTEGRATED NETWORKS: BUSINESS AND LEGAL CONSIDERATIONS
CLINICALLY INTEGRATED NETWORKS: BUSINESS AND LEGAL CONSIDERATIONS Claire Turcotte, Esquire, Bricker & Eckler LLP Jim Yanci, MS MT (ASCP), Dixon Hughes Goodman Agenda BUSINESS CONSIDERATIONS How Fast are
More informationFederal Fraud and Abuse Laws
Federal Fraud and Abuse Laws Remaining in Compliance while Attesting to Meaningful Use 1 Overview This presentation provides an overview of key Federal laws aimed at preventing healthcare fraud and abuse
More informationWhat is an ACO? What forms of organizations may become an ACO? IAMSS 30 th Annual Education Conference Pearls of Wisdom
IAMSS 30 th Annual Education Conference Pearls of Wisdom The Impact of Accountable Care Organizations (ACOs) and Health Care Reform on Credentialing, Privileging and Peer Review April 28-29, 2011 Michael
More informationAccountable Care Organizations
Building a Healthy ACO Compliance Program: Good Help ACO s Experience in Building Healthy Communities While Leveraging Existing Resources to Establish a Healthy and Effective ACO Compliance Program. Mary
More informationAccountable Care Organization Refinement Brief
Accountable Care Organization Refinement Brief The participants in the Medicare Shared Savings Program (MSSP), the Physician Group Practice Transition Demonstration (PGP-TD), and the Pioneer Accountable
More informationRE: File Code CMS-1345-NC2 Medicare Program Waiver Designs in Connection with the Medicare Shared Savings Program and Innovation Center
Donald Berwick, M.D., M.P.P. Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1345-NC2 Room 445-G Hubert H. Humphrey Building 200 Independence Ave. S.W.
More informationFraud & Abuse Waivers Under the Medicare Shared Savings Program
Fraud & Abuse Waivers Under the Medicare Shared Savings Program Robert G. Homchick Davis Wright Tremaine, LLP I. Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) fosters the development
More informationJanuary 14, 2011. Dear Chairman Issa:
The Honorable Darrell Issa Chairman Committee on Oversight and Government Reform U.S. House of Representatives 2157 Rayburn House Office Building Washington, D.C. 20515 Dear Chairman Issa: On behalf of
More informationMedicare and Commercial Accountable Care Organizations: A Retrospective and Prospective View
Medicare and Commercial Accountable Care Organizations: A Retrospective and Prospective View Troy Barsky, Esq. Jennifer Williams, Esq. Crowell & Moring Daniel Murphy, Esq. Bradley Arant Boult & Cummings
More informationACO Type Initiatives
If you proposed an ACO initiative, please fill our this Comparison of Elements for Participation in Medicare Shared Savings Program (MSSP) to State SIM ACO Test Proposal From Funding Opportunity Announcement:
More informationLegal Waivers under the Medicare Shared Savings Program: An Overview of the Options
Legal Waivers under the Medicare Shared Savings Program: An Overview of the Options Robert G. Homchick Davis Wright Tremaine LLP Arthur N. Lerner Crowell & Moring LLP Shared Savings Program: ACOs Medicare
More information2013 PLUS Medical PL Symposium Credentialing in the World of ACOs
2013 PLUS Medical PL Symposium Credentialing in the World of ACOs Chicago April 10-11, 2013 Credentialing in the World of ACOs MODERATOR: Fay A. Rozovsky, JD, MPH, DFASHRM, President, The Rozovsky Group,
More informationACOs: Fraud & Abuse Waivers and Analysis
ACOs: Fraud & Abuse Waivers and Analysis Robert G. Homchick and Sarah Fallows Davis Wright Tremaine, LLP I. Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) fosters the development
More informationACCOUNTABLE CARE ORGANIZATION FINAL REGULATIONS: ANALYSIS AND IMPLICATIONS* Prepared by Hooper, Lundy & Bookman, P.C. November 22, 2011 EDITORS
ACCOUNTABLE CARE ORGANIZATION FINAL REGULATIONS: ANALYSIS AND IMPLICATIONS* Prepared by Hooper, Lundy & Bookman, P.C. November 22, 2011 EDITORS Charles B. Oppenheim Los Angeles Lloyd A. Bookman Los Angeles
More informationRE: CMS-1416-P, Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations; Proposed Rule
Marilynn B. Tavenner Administrator Center for Medicare & Medicaid Services U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 445-G 200 Independence Avenue, SW Washington, DC
More informationCMS Next Generation ACO Model. Payment Models Work Group April 20 th, 2015
CMS Next Generation ACO Model Payment Models Work Group April 20 th, 2015 1 Why is there a new ACO model? To address concerns about certain design elements of the existing Pioneer Program and the MSSP
More informationFEDERAL TRADE COMMISSION / DEPARTMENT OF JUSTICE
FEDERAL TRADE COMMISSION / DEPARTMENT OF JUSTICE Federal Trade Commission ( FTC ) Antitrust Division of the Department of Justice ( DOJ ) Statement of Antitrust Enforcement Policy Regarding Accountable
More informationDecember 3, 2010. Dear Administrator Berwick:
Donald Berwick, M.D. Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building 200 Independence Avenue, SW Washington, DC 20201
More informationFRAUD AND ABUSE (SECTION-BY-SECTION ANALYSIS)
FRAUD AND ABUSE (SECTION-BY-SECTION ANALYSIS) (Information compiled from the Democratic Policy Committee (DPC) Report on The Patient Protection and Affordable Care Act and the Health Care and Education
More information