Attorney Michael James spoke to Michigan Association of CPAs yesterday on his presentation "Accountable Care Organizations 2.0". The presentation addressed the hundreds of pages of recently proposed regulations related to ACOs that represent the most dramatic overhaul of the Medicare Shared Savings Program since its inception. Other insights in the presentation:
- Current Regulatory Environment for Integrated Models
- How Environment Evolves Under Proposed Regulations
- Various Requirements Needed for ACOs
- Potential Risks Under Current ACO Models
To learn more, contact attorney Michael James at mjames@fraserlawfirm.com or 517-377-0823. Michael James is a senior attorney at Fraser Trebilcock, providing representation and counseling related to all facets of business enterprise and health care matters.
NOTE: Information contained in this presentation is only current as of the blog publish date. For updated information, refer to the Fraser Trebilcock Health Care Reform blog: fraserlawfirm.com
Learn some simple truths about how ACO's operate and function. Adapted from http://www.insight-txcin.org/post/why-accountable-care-organizations-succeed
Financial Management In Healthcare PowerPoint Presentation SlidesSlideTeam
Presenting this set of slides with name - Financial Management In Healthcare Powerpoint Presentation Slides. This PPT deck displays fourty slides with in depth research. Our topic oriented Financial Management In Healthcare Powerpoint Presentation Slides presentation deck is a helpful tool to plan, prepare, document and analyse the topic with a clear approach. We provide a ready to use deck with all sorts of relevant topics subtopics templates, charts and graphs, overviews, analysis templates. Outline all the important aspects without any hassle. It showcases of all kind of editable templates infographs for an inclusive and comprehensive Financial Management In Healthcare Powerpoint Presentation Slides presentation. Professionals, managers, individual and team involved in any company organization from any field can use them as per requirement.
Healthcare Billing and Reimbursement: Starting from ScratchDale Sanders
The healthcare billing environment in the US is a disaster. It creates huge waste in care and cost. As presented at the Cayman Islands International Healthcare Conference in October 2010, this slide deck suggests what the billing system might look like, if we could start over.
Learn some simple truths about how ACO's operate and function. Adapted from http://www.insight-txcin.org/post/why-accountable-care-organizations-succeed
Financial Management In Healthcare PowerPoint Presentation SlidesSlideTeam
Presenting this set of slides with name - Financial Management In Healthcare Powerpoint Presentation Slides. This PPT deck displays fourty slides with in depth research. Our topic oriented Financial Management In Healthcare Powerpoint Presentation Slides presentation deck is a helpful tool to plan, prepare, document and analyse the topic with a clear approach. We provide a ready to use deck with all sorts of relevant topics subtopics templates, charts and graphs, overviews, analysis templates. Outline all the important aspects without any hassle. It showcases of all kind of editable templates infographs for an inclusive and comprehensive Financial Management In Healthcare Powerpoint Presentation Slides presentation. Professionals, managers, individual and team involved in any company organization from any field can use them as per requirement.
Healthcare Billing and Reimbursement: Starting from ScratchDale Sanders
The healthcare billing environment in the US is a disaster. It creates huge waste in care and cost. As presented at the Cayman Islands International Healthcare Conference in October 2010, this slide deck suggests what the billing system might look like, if we could start over.
Comprehensive Medical Coding and Billing Training for the AAPC CPC Exam. Online Training with videos and Skype sessions. HIPAA Training included along with Medical Billing. Trainer is Dr Guptha, world record holder.
Accountable Care Organizations (ACOs) are organizations of health care providers who provide care to a group of patients. Created in an attempt to decrease the cost of service delivery and increase efficiency, value and profit, these organizations are new territory for the CPA professional. This presentation was given to the Michigan Association of Certified Public Accountants at their Healthcare Conference on April 23, 2013.
Delivered by Craig Brammer at CITIH 2011. Focus on discussion of regional and national initiatives and opportunities for regional partners to leverage them for driving healthcare improvements, public health and research.
This session will provide a broad perspective on the many initiatives related to HIT. Experts from the regional and national level will discuss data models, privacy concerns and adoption strategies from their different perspectives. Also addressed will be planning for NHIN direct adoption as a complimentary strategic to full HIEs.
Payment posting in RCM seems like an afterthought, something that happens after the “real” work of medical billing ends. After all, you’ve done the hard part and got the payments in the door. Payment Posting is the crucial step in the Revenue Cycle Management process.
Fraser Trebilcock teamed up with Lansing Regional Chamber of Commerce to present a free seminar to help employers keep up with changes related to Health Care Reform. This is the fourth presentation in the Business Education Series, titled "Navigating the ACA Marketplace: Guidance for Small Businesses and Individuals". Michael James, Senior Health Care and Business Attorney from Fraser Trebilcock, presented the keynote presentation.
Comprehensive Medical Coding and Billing Training for the AAPC CPC Exam. Online Training with videos and Skype sessions. HIPAA Training included along with Medical Billing. Trainer is Dr Guptha, world record holder.
Accountable Care Organizations (ACOs) are organizations of health care providers who provide care to a group of patients. Created in an attempt to decrease the cost of service delivery and increase efficiency, value and profit, these organizations are new territory for the CPA professional. This presentation was given to the Michigan Association of Certified Public Accountants at their Healthcare Conference on April 23, 2013.
Delivered by Craig Brammer at CITIH 2011. Focus on discussion of regional and national initiatives and opportunities for regional partners to leverage them for driving healthcare improvements, public health and research.
This session will provide a broad perspective on the many initiatives related to HIT. Experts from the regional and national level will discuss data models, privacy concerns and adoption strategies from their different perspectives. Also addressed will be planning for NHIN direct adoption as a complimentary strategic to full HIEs.
Payment posting in RCM seems like an afterthought, something that happens after the “real” work of medical billing ends. After all, you’ve done the hard part and got the payments in the door. Payment Posting is the crucial step in the Revenue Cycle Management process.
Fraser Trebilcock teamed up with Lansing Regional Chamber of Commerce to present a free seminar to help employers keep up with changes related to Health Care Reform. This is the fourth presentation in the Business Education Series, titled "Navigating the ACA Marketplace: Guidance for Small Businesses and Individuals". Michael James, Senior Health Care and Business Attorney from Fraser Trebilcock, presented the keynote presentation.
Fraser Trebilcock attorneys Beth Latchana and Mark Kellogg spoke this week at the Institute of Continuing Legal Education’s 27th Annual Tax Conference. In their overview of health care reform, they detailed most important aspects of the ACA, including: the health insurance marketplace, employer classification, the Pay or Play Mandate, reporting requirements, group health plan mandates, the individual insurance mandate, the Small Business Health Option Program, and the Small Business Health Care Affordability Tax Credits.
Attorney Edward J. Castellani recently spoke at the Michigan Association of Certified Public Accountants Nonprofit Conference on "Merger of Nonprofit Corporations – Legal and Accounting Issues". The presentation addressed how two nonprofits can legally merge into one nonprofit entity. He also addressed the appropriate steps that need to be taken by both directorship and membership corporations mergers to be approved by the Attorney General.
In a seminar titled, “Get Your Ducks In A Row,” Fraser Trebilcock attorney Marlaine C. Teahan shared her legal experience with families on topics that included: differences between wills and trusts and how to choose between them, the best planning ideas for minor and special needs children, and more.
Summary of the Changes to the Michigan Nonprofit Corporations Act that Affect...Fraser Trebilcock Lawyers
Effective January 15, 2015, Governor Snyder signed into law Senate Bills 623, 624 and 929. These three Bills amend the Michigan Nonprofit Corporation Act (the "Act") which is the law under which most trade associations operate. Some of the amendments require action by management to amend bylaws or articles of incorporation, but most will not.
In early July, the Department of Treasury announced it is delaying a key mandate of the Affordable Care Act: what's known as the 'Pay or Play' mandate. While pushing pause on this mandate gives large employers another year to prepare, we strongly advise businesses not to wait to start making strategic decisions. For more information, contact Fraser Trebilcock Senior Health Care and Business Attorney Mike James at mjames@fraserlawfirm.com or 517.377.0823. You can also find more information at www.milhealthlaws.com.
Retirement plans are subject to a very complex web of regulations governing their administration, and mistakes inevitably happen, even in the best-run plans. Recently, Brian Gallagher presented to Plante Moran on the various programs available for correcting such errors. If your organization would be interested in a similar presentation, or if you have questions about correcting errors involving your own retirement plan, please contact Fraser Trebilcock Employee Benefits attorney, Brian Gallagher at 517.377.0886 or bgallagher@fraserlawfirm.com.
Melisa Mysliwiec's presentation addresses social security benefits for children with disabilities for both themselves and their families and the proper steps to claim supplemental security income. Other insights from her talk included:
- Eligibility for Supplemental Security Income for Children with Disabilities
- Resources Included in Supplemental Security Income
- Proper Steps for Supplemental Security Income for Disabled Adult Children
- Correct Methods for Contacting the Social Security Administration
For more information on creating and revising plans for children with disabilities, contact attorney Melisa M.W. Mysliwiec at mmysliwiec@fraserlawfirm.com or 616-301-0800.
Final regulations recently announced by the Obama Administration give two levels of delay to employers who had previously been required to offer insurance coverage to their employees next year. With this second round of delays, come a second wave of questions from employers.
This week, Attorney Michael James and Rehmann Group’s Don McAnelly addressed key Affordable Care Act regulations and deadlines in a webinar.
At the State Bar of Michigan's Upper Michigan Legal Institute 2014, attorney Marlaine Teahan spoke on various Probate and Estate Planning updates, including durable powers of attorney and the importance of including digital assets in estate planning.
Health Care Reform Strategies for Small Employers:
• Health Care Tax Credits and Penalties
• The Recently Delayed Pay or Play Mandate
• Health Insurance Exchanges
• SHOPs
• Other Cost-Savings Opportunities
• Strategic Decision Making for Large and Small Employers
• And more!
Understanding reimbursement models for 2014, including Accountable Care Organizations (ACO's), Private Payer Models, and Health Care Reform Initiatives.
Quality Payment Program (MACRA) Proposed RuleMick Brown
The Quality Payment Program, established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), began in 2017, known as the transition year. The Program’s main goals are to:
Improve health outcomes.
Spend wisely.
Minimize burden of participation.
Be fair and transparent.
The Quality Payment Program has 2 tracks: (1) The Merit-based Incentive Payment System (MIPS) and (2) Advanced Alternative Payment Models (Advanced APMs).
Because the Quality Payment Program brings significant changes to how clinicians are paid within Medicare, the Centers for Medicare & Medicaid Services (CMS) is continuing to go slow and use stakeholder feedback to find ways to streamline and reduce clinician burden. CMS has engaged more than 100 stakeholder organizations and over 47,000 people since January 1, 2017 to raise awareness, solicit feedback, and help clinicians prepare to participate. Based on stakeholder feedback, CMS established transition year policies from the clinician perspective, such as:
Giving clinicians the option to choose how they’ll participate (also known as Pick Your Pace).
Having a low-volume threshold that exempts many clinicians with a low volume of Medicare
Part B payments or patients.
Allowing flexibilities for clinicians who are considered hospital-based or have limited face-to-
face encounters with patients (referred to as non-patient facing clinicians).
As the Quality Payment Program moves into the second year, CMS wants to ensure that there is meaningful measurement and the opportunity for improved patient outcomes while minimizing burden, improving coordination of care for patients, and supporting a pathway to participation in Advanced APMs.
Delivering Care Under the MACRA Final Rule: Implementation Considerations and...Epstein Becker Green
Presented November 18, 2016, by Mark Lutes, Robert F. Atlas, and Lesley R. Yeung of Epstein Becker Green and EBG Advisors.
http://www.ebglaw.com
http://www.ebgadvisors.com
This open door forum held on Tuesday, April 25, 2017 provided more detailed information on how to complete the Participant List tool for submission with your application to the Next Generation ACO Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
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http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held a Comprehensive Care for Joint Replacement Model webinar on proposed rule changes to the model on September 7, 2016.
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CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
In follow-up to the March 10, 2015 announcement of the Next Generation Accountable Care Organization (ACO) Model of payment and care delivery, the Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted the fourth in a series of open door forums on Tuesday, April 7, 2015. This open door forum focused on benefit enhancements and beneficiary care coordination reward.
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CMS Innovation Center
http://innovation.cms.gov
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http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Community Health Access and Rural Transformation (CHART) Model team hosted an overview webinar on Tuesday, August 18, 2020 from 1:00 - 2:30 PM EDT. Attendees had the opportunity to hear an overview of the CHART Model, including its objectives, eligible participants and their roles, payment options, and timeline.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Next Generation ACO Model team hosted an open door forum on Tuesday, March 28, 2017. The Next Generation Model features three payment rule waivers, referred to as benefit enhancements. This open door forum provided an overview of the Model’s three benefit enhancements.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
How to Obtain Permanent Residency in the NetherlandsBridgeWest.eu
You can rely on our assistance if you are ready to apply for permanent residency. Find out more at: https://immigration-netherlands.com/obtain-a-permanent-residence-permit-in-the-netherlands/.
NATURE, ORIGIN AND DEVELOPMENT OF INTERNATIONAL LAW.pptxanvithaav
These slides helps the student of international law to understand what is the nature of international law? and how international law was originated and developed?.
The slides was well structured along with the highlighted points for better understanding .
ALL EYES ON RAFAH BUT WHY Explain more.pdf46adnanshahzad
All eyes on Rafah: But why?. The Rafah border crossing, a crucial point between Egypt and the Gaza Strip, often finds itself at the center of global attention. As we explore the significance of Rafah, we’ll uncover why all eyes are on Rafah and the complexities surrounding this pivotal region.
INTRODUCTION
What makes Rafah so significant that it captures global attention? The phrase ‘All eyes are on Rafah’ resonates not just with those in the region but with people worldwide who recognize its strategic, humanitarian, and political importance. In this guide, we will delve into the factors that make Rafah a focal point for international interest, examining its historical context, humanitarian challenges, and political dimensions.
Introducing New Government Regulation on Toll Road.pdfAHRP Law Firm
For nearly two decades, Government Regulation Number 15 of 2005 on Toll Roads ("GR No. 15/2005") has served as the cornerstone of toll road legislation. However, with the emergence of various new developments and legal requirements, the Government has enacted Government Regulation Number 23 of 2024 on Toll Roads to replace GR No. 15/2005. This new regulation introduces several provisions impacting toll business entities and toll road users. Find out more out insights about this topic in our Legal Brief publication.
WINDING UP of COMPANY, Modes of DissolutionKHURRAMWALI
Winding up, also known as liquidation, refers to the legal and financial process of dissolving a company. It involves ceasing operations, selling assets, settling debts, and ultimately removing the company from the official business registry.
Here's a breakdown of the key aspects of winding up:
Reasons for Winding Up:
Insolvency: This is the most common reason, where the company cannot pay its debts. Creditors may initiate a compulsory winding up to recover their dues.
Voluntary Closure: The owners may decide to close the company due to reasons like reaching business goals, facing losses, or merging with another company.
Deadlock: If shareholders or directors cannot agree on how to run the company, a court may order a winding up.
Types of Winding Up:
Voluntary Winding Up: This is initiated by the company's shareholders through a resolution passed by a majority vote. There are two main types:
Members' Voluntary Winding Up: The company is solvent (has enough assets to pay off its debts) and shareholders will receive any remaining assets after debts are settled.
Creditors' Voluntary Winding Up: The company is insolvent and creditors will be prioritized in receiving payment from the sale of assets.
Compulsory Winding Up: This is initiated by a court order, typically at the request of creditors, government agencies, or even by the company itself if it's insolvent.
Process of Winding Up:
Appointment of Liquidator: A qualified professional is appointed to oversee the winding-up process. They are responsible for selling assets, paying off debts, and distributing any remaining funds.
Cease Trading: The company stops its regular business operations.
Notification of Creditors: Creditors are informed about the winding up and invited to submit their claims.
Sale of Assets: The company's assets are sold to generate cash to pay off creditors.
Payment of Debts: Creditors are paid according to a set order of priority, with secured creditors receiving payment before unsecured creditors.
Distribution to Shareholders: If there are any remaining funds after all debts are settled, they are distributed to shareholders according to their ownership stake.
Dissolution: Once all claims are settled and distributions made, the company is officially dissolved and removed from the business register.
Impact of Winding Up:
Employees: Employees will likely lose their jobs during the winding-up process.
Creditors: Creditors may not recover their debts in full, especially if the company is insolvent.
Shareholders: Shareholders may not receive any payout if the company's debts exceed its assets.
Winding up is a complex legal and financial process that can have significant consequences for all parties involved. It's important to seek professional legal and financial advice when considering winding up a company.
Responsibilities of the office bearers while registering multi-state cooperat...Finlaw Consultancy Pvt Ltd
Introduction-
The process of register multi-state cooperative society in India is governed by the Multi-State Co-operative Societies Act, 2002. This process requires the office bearers to undertake several crucial responsibilities to ensure compliance with legal and regulatory frameworks. The key office bearers typically include the President, Secretary, and Treasurer, along with other elected members of the managing committee. Their responsibilities encompass administrative, legal, and financial duties essential for the successful registration and operation of the society.
A "File Trademark" is a legal term referring to the registration of a unique symbol, logo, or name used to identify and distinguish products or services. This process provides legal protection, granting exclusive rights to the trademark owner, and helps prevent unauthorized use by competitors.
Visit Now: https://www.tumblr.com/trademark-quick/751620857551634432/ensure-legal-protection-file-your-trademark-with?source=share
DNA Testing in Civil and Criminal Matters.pptxpatrons legal
Get insights into DNA testing and its application in civil and criminal matters. Find out how it contributes to fair and accurate legal proceedings. For more information: https://www.patronslegal.com/criminal-litigation.html
PRECEDENT AS A SOURCE OF LAW (SAIF JAVED).pptxOmGod1
Precedent, or stare decisis, is a cornerstone of common law systems where past judicial decisions guide future cases, ensuring consistency and predictability in the legal system. Binding precedents from higher courts must be followed by lower courts, while persuasive precedents may influence but are not obligatory. This principle promotes fairness and efficiency, allowing for the evolution of the law as higher courts can overrule outdated decisions. Despite criticisms of rigidity and complexity, precedent ensures similar cases are treated alike, balancing stability with flexibility in judicial decision-making.
Car Accident Injury Do I Have a Case....Knowyourright
Every year, thousands of Minnesotans are injured in car accidents. These injuries can be severe – even life-changing. Under Minnesota law, you can pursue compensation through a personal injury lawsuit.
3. Medicare Shared
Savings Program (MSSP)
MSSP designed to improve beneficiary outcomes
and increase value of care by promoting:
Accountability for patient population;
Coordination of care for services;
Investment in infrastructure; and
Redesign of care processes.
If Medicare expenditures are lower
than benchmark targets, ACO receives
portion of savings.
4. What are ACOs?
ACOs are the vehicles through which
providers/suppliers participate in the MSSP.
A legal entity designed to manage and coordinate care
for Medicare fee-for-service beneficiaries under the
MSSP.
Accountable for the costs associated with its
beneficiary population.
Responsible for the quality of care for its beneficiary
population.
5. Fundamental Principles of ACOs
Improve
Care for
Beneficiari
es
Enhance Health
in its
Population
Reduce
Growth of
Beneficiary
Expenditur
es
What are ACOs?
6. New Regulations
In December 2014, the Department of Health and
Human Services (HHS) issued hundreds of pages of
proposed changes to the MSSP and ACOs.
Comment period closed on February 6, 2015.
Unclear when final rule will be issued.
The proposed rule represent the largest set of
changes to the MSSP and rules governing ACOs
since the implementation of the ACA.
7. Major Provisions
ACO Participation Agreements.
Eligibility Requirements.
ACO Reporting Requirements.
Legal Structure, Governing Body, Leadership,
Coordination.
Renewal of Track 1 Participation Agreement.
Data Sharing Requirements.
Beneficiary Assignment.
ACO Benchmarking.
New Participation Model: Track 3.
Revision to Repayment Mechanisms.
8. Key Definitions
ACO Participant: An entity, not a practitioner, with a
TIN. May be comprised of one or more ACO
providers/suppliers whose services are billed under the
TIN of the ACO Participant.
ACO Professional: An individual who bills for items or
services furnished to Medicare FFS beneficiaries under a
Medicare billing number assigned to the TIN.
An ACO provider/supplier who is either:
A physician, physician assistant, nurse practitioner or clinical
nurse specialist.
9. Key Definitions
ACO Provider/Suppler: an individual or entity that:
is a provider or supplier;
is enrolled in Medicare;
Bills for items and services under the TIN of an ACO participant; and
Is certified by the ACO as an ACO provider/supplier.
A supplier is a physician or other practitioner, or an entity other
than a provider, that furnishes health care services.
A provider is a hospital, CAH, skilled nursing facility,
comprehensive outpatient rehabilitation facility, home health
agency, hospice, clinic, rehabilitation agency, public health
agency that provides outpatient care, or a community mental
health center that furnishes partial hospitalization services.
10. ACO Participation Agreements
Must have contract between ACO and ACO
provider/supplier that:
Requires compliance with MSSP and other laws;
Outlines rights and obligations of ACO participant;
Discusses quality reporting requirements;
Outlines beneficiary notification requirements;
Explains the impact on other programs;
Requires participant to update enrollment information;
Allows for remedial action against participant; and
Outlines termination procedures and consequences.
11. Eligibility Requirements
MSSP requires an ACO to have at least 5,000
beneficiaries assigned to it during the 3 year
benchmark period.
New proposal:
Use actual data for first 2 years; estimate for 3rd year
based on most recent data available with up to 3-month
claims run out.
After ACO is accepted into the program, if the final
assignment numbers for 3rd benchmark year are less
than 5,000, ACO is not automatically terminated from
program.
12. Eligibility Requirements
Increased flexibility for ACO eligibility.
If ACO population falls below 5,000 beneficiaries:
Current: ACO receives warning letter and placed on
Corrective Action Plan (CAP). If ACO does not reach
beneficiary level in next year, terminated.
Proposed: Provide the ACO with adequate time to complete
CAP. Letter will indicate deadline.
Allows the ACO to take appropriate action to increase numbers.
HHS has also proposed making the CAP discretionary.
Example: If ACO has already submitted a request to add
ACO participants, CAP may not be required.
13. Reporting Requirements
Certified list of ACO participants and ACO
providers/suppliers:
Start of each agreement period and before each
performance year, provide CMS with a complete and
certified list of its ACO participants.
Report changes in ACO participant and provider/supplier
enrollment status in PECOS within 30 days after change.
Remain required to certify that list is true, accurate and
complete.
14. Reporting Requirements
Managing changes to ACO participants:
Expect that ACO participant remain is ACO full 3 years.
Current: must notify CMS within 30 days of addition or removal of
ACO participant.
Proposed: new procedure for adding and removing:
1) To add an ACO participant, must submit request to CMS. CMS must
approve addition before effective.
2) If approved, entity will not be added until beginning of next performance
year – can’t us claims until then.
3) Must notify CMS within 30 days of termination and submit a notice of
removal.
Adjustments will be made to benchmark, assignment of
beneficiaries, quality reporting sample and ACO reporting.
Historic data only; changes do not affect current requirements/system.
15. Reporting Requirements
Significant Changes to an ACO:
No longer able to meet eligibility requirements; or
50% or more change in the number or identity of ACO
participants.
Must notify CMS. CMS will determine if ACO is still
eligible.
A significant change in control does not necessarily
result in termination of ACO’s participation agreement.
CMS may make its own decision that a significant
change in control has occurred.
16. ACO Legal Structures
Legal structure clarification:
Must form a legal entity separate from any ACO
participant if the ACO participants have unique TINs.
Do you form a new entity or can you use an existing
entity for your ACO?
17. Types of ACOs
Integrated Delivery System Model ACO
CMS
Health System ACO
Hospital Physicians
Skilled
Nursing
Facility
Etc.
18. Types of ACOs
PHO Model ACO
PHO
ACO
Hospital
Independent
Practice
Assn.
CMS
19. Types of ACOs
Independent Practice Association Model ACO
IPA
ACO
CMS
PhysicianPhysicianPhysicianPhysician
20. Types of ACOs
Group Practice Model ACO
Group
Practice
ACO
CMS
SpecialistsHospital
21. ACO Governance
3 Criteria for governing body:
1) governing body of ACO must be same governing
body of the legal entity that is the ACO;
2) governing body of ACO may not be the same
governing body as any ACO participant; and
3) governing body must meet other requirements of
ACA, especially the fiduciary duty requirement.
22. ACO Governance
Composition of the Governing Body:
Propose to remove the flexibility for ACOs to deviate
from the requirement that at least 75% control of an
ACO’s governing body must be held by ACO
participants.
Propose to prohibit an ACO provider/supplier from
serving as the beneficiary representative.
23. ACO Coordination of Care
Strong focus in proposed rules on use of
technology.
Require applicant to describe how it will encourage
and promote use of enabling technologies for
improving care coordination for beneficiaries.
Require existing ACOs to submit major milestones
or performance targets it will use in each
performance year to assess the progress of its ACO
participation.
Sought comments on use of telehealth.
24. Renewal of ACO Agreement
Proposed extension of Track 1 ACOs:
Current: After initial, 3 year term under Track 1, ACO
transitions to Track 2, risk model.
Proposed: Allow Track 1 ACOs to renew Track 1
contract for an additional 3 years if:
ACO has met quality performance standard in at least 1 of
first 2 years; and
Have not generated losses that exceed the negative
minimum savings rate in both of first 2 years.
The maximum shared savings rate drops from 50% to
40% in second term under Track 1.
25. Data Sharing
Current:
ACO must notify beneficiary of data sharing and give
beneficiary opportunity to decline.
Administrative difficulties, delays, confusion.
Proposed:
ACO provides written notification, via signs, regarding
data sharing and opportunity for beneficiary to decline
by calling Medicare.
Beneficiary communicates directly with CMS, not ACO.
ACO no longer required to send out letters.
26. Beneficiary Assignment
Current:
Two step process:
Step 1 – assign beneficiaries by primary care physicians.
Step 2 – If beneficiary did not receive care from PCP, look
to services provided by other providers/suppliers.
Proposed:
Two steps revised:
Step 1 – include nurse practitioners, physician assistants and
clinical nurse specialists to recognize primary care services.
Step 2 – remove certain specialty types whose services are
not likely to be indicative of primary care services.
27. ACO Benchmarking
Significant changes in benchmarking are being evaluated.
Alternative methodologies are being considered for
establishing, updating and resetting ACO financial
benchmarks:
1) Use of Regional FFS expenditures, instead of national FFS
expenditures in establishing and updating benchmark.
2) Use of regional FFS cost data to make ACO benchmarks
gradually more independent of the ACO’s past performance and
more dependent on the ACO’s success in being more cost
effective relative to its local market.
3) Resetting benchmarks in subsequent years by equally
weighting three benchmark years and/or accounting for shared
savings payments receive by ACO in prior agreement period.
28. ACO Benchmarking
Changes to calculations related to the benchmark
that would support these options:
Risk adjustment normalization;
Coding intensity adjustments;
Comparison group definitions;
Adjustments for ACO composition changes;
The timeline for transition to regional FFS costs; and
Other potential adjustments.
ACO Benchmarking is a big portion or proposed
rule.
29. ACO Participation:
Track 3 Model
Proposed Track 3 performance, risked-based model:
Prospective assignment of beneficiaries to ACO.
Assigned prior to start of performance year.
More narrowly defined target population and greater certainty
about where to focus care redesign processes.
Sharing Rate: 75%
Track 1, 50% Track 2, 60%
Performance payment limit not to exceed 20% of benchmark.
Track 2 is 15%.
Downside Cap: 15%
Fixed minimum savings rate/minimum loss rate of 2%.
30. Repayment Mechanisms
Current: ACOs may demonstrate their ability to
repay shared losses by obtaining:
Reinsurance, placing funds into escrow, obtaining surety
bonds, establishing a line of credit, or establish another
appropriate repayment mechanism that will ensure
ability to repay.
Proposed: Limit the types of repayment mechanisms
to:
Placing funds into escrow, obtaining a surety bond, or
establishing a line of credit.
31. Potential Risk
ACO agrees to be subject to all statutory and most
regulatory changes that become effective during the
term of its agreement.
Currently, the only regulatory changes that an ACO will
not be subject to are:
Eligibility requirements concerning the structure and
governance of the ACO;
Calculation of the sharing rate; and
Beneficiary assignment.
An ACO is subject to regulatory changes related to the
quality performance standard.
32. Potential Risk
Proposed Rule:
Require ACOs to be subject to any regulatory changes
regarding beneficiary assignment that become effective
during an agreement period.
Would remove the exception currently in place.
Operational policies enable annual adjustments to ACO
benchmarks to account for changes in beneficiary
assignment resulting from changes in ACO participants.
Therefore, CMS believes it should also be able to
adjust benchmarks based on regulatory changes to
beneficiary assignment methodology.
33. Additional Risks
Fiduciary Duties and Ethical Conflicts
Corporate Practice of Medicine
Stark Laws, Anti-Kickback Statute and Civil
Monetary Penalties