ACO & Medicare Shared Savings Program Office Manager and Front Desk Staff Training Maureen Pence RN BSN CCM mpence@npnwa.net 253 627 1151 February 2013
Agenda All slides and attachments will be e mailed to attendees after the presentation Accountable Care Organization (ACO) Medicare Shared Savings Program (MSSP) CMS required documents and processes (ACO & Clinics) Physician Quality Reporting System (PQRS) MSSP Quality Measures Care Coordination and Case Management
Franciscan Health Systems and Northwest Physicians Network Accountable Care Organization (ACO) -Franciscan Northwest Physicians Health Network LLC effective 1/1/13
ACO Vision An ACO Promotes seamless coordinated care Puts the beneficiary and family at the center Remembers patients over time and place Attends carefully to care transitions Manages resources carefully and respectfully Proactively manages the beneficiary s care Evaluates data to improve care and patient outcomes Innovates around better health, better care and lower growth in costs through improvement Invests in team-based care and workforce
CMS has established a website that describes the overall ACO program and additional ACO resources: http://www.cms.gov/sharedsavingsprogram/ Located on www.cms.gov under Medicare tab
Medicare Shared Savings Program (MSSP) Includes Fee for Service beneficiaries seen by an ACO provider in the past year. Beneficiaries roster from CMS provided to the ACO quarterly but does not include addresses. ACO is required to mail to the beneficiaries a notice to patients 30 days prior to request any beneficiary data.
Notice to Patients Template Form (printed on physician s letterhead) attachment A Covers the following topics We re working to improve your care You can still see any doctor or hospital You control personal information You can choose not to share your personal health information Where to call with questions
Declining to Share PHI Template Consent to Change Personal Health Info Attachment B & C This form is required if beneficiaries do not want to share their Medicare personal health information with the ACO Must be made available to any beneficiary for whom the ACO intends to request data Assures beneficiaries that their decision not to share personal information with the ACO will remain in effect unless/until they change their preference There is a separate form Consent to Change Personal Health Information used if beneficiaries want to reverse their opt-out designation and allow release of Medicare data to ACO s Beneficiaries can also call 1-800 MEDICARE instead of signing any of the forms
Beneficiary Fact Sheet-ACOs and You: FAQs for People with Medicare Attachment D Written specifically for beneficiaries covers: If my doctor's in an ACO, can I still see whatever doctor I want? Is an ACO a Health Maintenance Organization (HMO), managed care or an insurance company? How do I know if my doctor is in an ACO? What should I expect if my doctor is in an ACO? What rights do I have if my doctor is in an ACO/ Who can read my medical information? And will it be protected? How will and ACO lead to better care for me? Where can I find more information about ACOs?
ACO Provider Fact Sheet-Summary of Final Rule Provisions Attachment E Written specifically for providers covers: Overview and background of ACOs under the Medicare Shared Savings Program ACOs and the Medicare Beneficiary Eligibility Requirements for an ACO Monitoring ACO Performance and Termination of Agreement Tying payment to improve Care at Lower cost Resources
MSSP Script for Front Desk Staff Attachment F Topics includes: What is an ACO? How to know if a specific doctor is in an ACO and other physician participation questions Data sharing and privacy issues Impact of the ACO on beneficiaries Beneficiary questions related to physicians letter of notification
Physician Practice Poster Attachment G Required to be posted in common area in office Includes: Notice that practice is participating in a new Medicare care coordination program What is an Accountable Care Organization (ACO)? ACO s don t change patient s medical benefits How will an ACO help physicians coordinate care?
Beneficiary Notification Process Guidance In accordance with 42 CFR 425.310, 425.312, 425.704(d), and 425.708: I. Provider offices in ACO must do all of the following: a. Notify beneficiaries at the point of care that they are participating in the Shared Saving Program. b. Make available standardized written notices regarding participation in an ACO and, if applicable, offer the beneficiary the opportunity to decline data sharing by: Mail Beneficiary initial written notification and opportunity to decline data sharing. If no response within 30 days to opt-out, data requests to CMS will occur. (NPN will mail these letters to your beneficiaries on your behalf if you provide us with addresses.) AND follow-up on with the beneficiary at the first office visit and again explain your participation with the ACO and provide them the opportunity to decline data sharing. c. Fax all documentation of in- office notifications forms to NPN 253 627 4708 for CMS reporting purposes
Data Files from CMS are monthly disclosure of Part A, Part B and Part D monthly claims data for assigned Medicare beneficiaries, subject to each Medicare beneficiary s election to opt-out. Does not include Chemical Dependency or behavioral health claims Use is limited to developing processes and engaging in appropriate activities relating to care coordination and improving the quality and efficiency of care May not be used to reduce, limit or restrict care for specific individuals
2013 Physician Quality Reporting System (PQRS) 22 Measures Attachment H PQRS eligible Taxpayer Identification Numbers (TIN) within an ACO will be eligible to receive the PQRS incentive payments for each calendar year in which their ACO fully and completely report the ACO GPRO measures. ACO providers within an ACO may only participate under their ACO participant Taxpayer Identification Number as an ACO practice under the Shared Savings Program for purposes of receiving an incentive payment under the PQRS. To ensure no duplication in PQRS incentive payments, Centers for Medicare & Medicaid Services will notify the PQRS of Taxpayer Identification Numbers that become part of an Accountable Care Organization. An ACO, on behalf of its providers will report the quality measures. Eligible professionals within an ACO who qualify for a Physician Quality Reporting incentive payment in each ACO participant Taxpayer Identification Number will receive an incentive, for those years an incentive is available, based on the allowed Medicare Part B charges under the physician fee schedule for that Taxpayer Identification Number. Those who report satisfactorily for the 2013 program year may avoid the 2015 payment adjustment.
ACO Quality Performance Standards 33 Measures (reduced from 65) Attachment I 1) Patient/Caregiver Experience (7 measures) 2) Care Coordination/patient safety (6 measures) 3) Preventive Health (8 measures) 4) At risk Population: Diabetes (1 measure and 1 composite consisting of 5 measures) Hypertension (1 measure) Ischemic Vascular Disease (2 measures) Heart Failure (1 measure) CAD (1 composite consisting of 2 measures)
Care Coordination, Routine Case Management and Complex Case Management Attachment J Patients who may need to be referred: Difficulty managing multiple medical conditions Lack of social support systems, resulting in poor management of their health Experiencing barriers impacting health, finances, or medical insurance Difficulty coordinating complicated health care needs, i.e. multiple providers, intense treatment programs. Call (253) 722-0312 and ask for a Nurse Case Manager or fax NPN referral to (253) 627-4708
Questions?