Accountable Care Organizations

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Physician Fee Schedule Final Rule (PFS Rule), which contains a number of significant substantive changes to Medicare payment practices and policies. The PFS Rule will be officially published in the Federal Register on November 23, 2018. The PFS Rule also includes an interim final rule implementing amendments to federal telehealth regulations to maintain consistency with recent changes to the Social Security Act to address the opioid crisis enacted in October 2018 through the SUPPORT for Patients and Communities Act.
Continue Reading 2019 Physician Fee Schedule Rule Review: Option to Extend MSSP Agreements for Currently-Expiring ACOs Finalized

The Centers for Medicare & Medicaid Services (CMS) recently published a Proposed Rule, primarily intended to modify certain Medicare payment policies.  The Proposed Rule contains several provisions that address the growing use of telehealth. CMS noted that it had received many suggestions regarding the expansion of access to telehealth as well as appropriate pay for the same, in response to its call for comments in the CY 2018 Medicare physician fee schedule (PFS) proposed rule.
Continue Reading Medicare Proposes Revised Telehealth Services and Payments

On August 17, 2018, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule (Proposed Rule) that proposes a comprehensive overhaul of the Medicare Shared Savings Program (MSSP).  Among other changes, CMS proposes to:

  • replace the current three-track program with two options (Basic and Enhanced),
  • establish a ‘glide path’ that propels accountable care organizations (ACOs) towards acceptance of performance-based down-side risk,
  • update the benchmarking methodology to incorporate regional trends from the start of an ACO’s participation in the MSSP,
  • expand the use of telehealth services by ACOs, and
  • permit ACOs to provide monetary rewards to beneficiaries for the receipt of certain primary care services.


Continue Reading CMS Identifies “Pathway to Success” for Accountable Care in Proposed Rule that Would Significantly Change Shared Savings Program

In December, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (Final Rule) implementing new and revised episode payment models (EPMs) developed by the CMS Innovation Center.  The Final Rule continues CMS’ transition of Medicare payment methodologies away from fee-for-service and towards value-based payments, including by incentivizing care coordination efforts and tying payments to quality improvement.

New EPMs:  The Final Rule implements three new EPMs for episodes of care surrounding (i) acute myocardial infarction (AMI); (ii) coronary artery bypass graft (CABG); and (iii) surgical hip/femur fracture treatment excluding lower extremity joint replacement (SHFFT). Each episode of care encompasses a beneficiary’s inpatient stay as well as all related care within 90 days after discharge covered under Medicare Parts A and B. The initial performance year for the EPMs will start July 1 and expire December 31, 2017, and be followed by four successive performance years (2018-2021). Participation in the AMI and CABG EPMs will mandatory for acute care hospitals located in 98 randomly-selected metropolitan statistical areas (MSAs), and participation in the SHFFT EPM will be mandatory for hospitals in the 67 MSAs that currently participate in CMS’s comprehensive care for joint replacement model (CJR Model). The EPMs are designed to incorporate downside risk starting in 2019, but allow participants to assume downside risk in 2018 in order to qualify for potential incentive payments under the Medicare Access and CHIP Reauthorization Act (MACRA), by participating in an Advanced Alternative Payment Model.
Continue Reading CMS Final Rule on Episode Payment Models and Revisions to CJR Model

On December 20, 2016, CMS announced the formation of a new participation track under the Medicare Shared Savings Program (MSSP) – the Medicare ACO Track 1+ Model – which will start in 2018. Accountable care organizations (ACOs) participating in this model will agree to accept more limited downside risk than ACOs participating in Track 2

On October 29, 2015, the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG), Health & Human Services issued a final rule (Final Rule) regarding waivers (ACO Waivers) of the physician self-referral law (Stark law), the federal Anti-Kickback Statute, and the Civil Monetary Penalties Law (CMP) provision relating to beneficiary inducements for Medicare accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP). The ACO Waivers waive the application of these fraud and abuse laws to certain ACO activities that are reasonably related to the purposes of the MSSP. The Final Rule’s ACO Waivers are effective as of October 29, 2015.
Continue Reading Fraud And Abuse Waivers For ACOs