Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers who work together to give coordinated care to Medicare patients. Their goal is to make sure patients get the right care at the right time while avoiding repeat tests and medical mistakes. Medicare’s Shared Savings Program, run by the Centers for Medicare & Medicaid Services (CMS), sets rules for how ACOs work and how they report on quality and cost.
Before the Bipartisan Budget Act (BBA) of 2018, Medicare telehealth services were limited by rules about where patients could be and where services had to be provided. Telehealth visits were mostly paid for only if the patient lived in a rural Health Professional Shortage Area (HPSA) and the visit happened at a set originating site, like a healthcare facility. This limited telehealth a lot, especially for patients in cities or those who could not travel to specific places for virtual visits. Very few Medicare patients used telehealth back then.
One important change allowed some ACOs to ignore the rules about where patients lived and the site where telehealth services happened. Starting January 1, 2020, ACO providers could offer telehealth visits to patients no matter where the patient lived or if the patient was at a special site. This meant an ACO could use a patient’s home as the place for telehealth, giving more people in cities, suburbs, and rural areas access to telehealth.
This change helped make telehealth a usual part of care for many Medicare patients in ACOs. It made it easier and quicker to get primary and specialist care without visiting a clinic in person. During the COVID-19 pandemic, telehealth use grew fast. It went up from 6.9% in early 2020 to 46.7% by mid-2020. Even by late 2023, telehealth use was still much higher than before the pandemic, with 12.7% of Medicare patients using it.
The BBA also lets ACOs pay Medicare patients cash rewards of up to $20 for certain primary care services. This program, called the Beneficiary Incentive Program, encourages patients to take part in their care and use primary care correctly. This payment helps patients stick with their ACO, which can make care coordination work better.
Starting in 2020, Medicare Advantage (MA) plans could include telehealth as a basic benefit. This change removed earlier limits that mostly let people in rural areas use telehealth. MA plans could offer more kinds of telehealth services, often as part of care plans to improve patient satisfaction and health outcomes.
The BBA allowed telehealth services for patients with End-Stage Renal Disease (ESRD) to do required monthly checkups remotely at home or dialysis centers with no location limits. This was a big relief for patients who need frequent care.
Also, changes in home health care payments under Medicare starting in 2020 encouraged care models that use telehealth. Payment periods were shortened to 30 days to support more virtual checkups and visits during home care.
ACOs must keep quality standards and follow CMS rules to join the Shared Savings Program. Telehealth services must meet the same quality checks as in-person care. ACOs report quality data yearly through the Alternative Payment Model Performance Pathway (APP). They must also keep a public website that shares their performance and compliance information.
Telehealth use under the BBA does not reduce reporting rules. It makes sure telehealth services meet quality requirements, are recorded properly, and fit into patient care plans.
Telehealth use varies for different groups. In 2023, patients in cities used telehealth more (27%) than those in rural areas (19%). This difference likely comes from better internet and technology access in cities. Use was highest among Asian and Pacific Islander patients (31%) and Hispanic patients (30%), showing telehealth’s use in different communities.
Patients with End-Stage Renal Disease (37%) and those who qualify for both Medicare and Medicaid (34%) also had higher telehealth use. This shows that virtual care helps manage complex and long-term conditions.
Medicare pays telehealth providers rates similar to in-person visits, especially for behavioral health care where the payment is permanent no matter the patient’s location. Starting January 2025, however, payment rates for most non-behavioral telehealth services are planned to go back to lower facility rates unless new laws are passed. This could affect providers’ willingness to offer telehealth.
The Congressional Budget Office said that extending telehealth flexibilities through December 2024 would cost $2.4 billion. This shows telehealth is being used more and covers more services.
At the same time, the Bipartisan Budget Act extended Medicare sequester cuts through 2027, which reduce provider payments by 2%. This cut could create financial challenges for telehealth providers in ACOs.
The Center for Medicare and Medicaid Innovation (CMMI) has played a key role in advancing telehealth through payment changes and pilot programs with ACOs. Created under the Affordable Care Act, CMMI has started over 40 models including more than 18 million patients and 200,000 providers.
In 2016, risk-bearing ACOs saved Medicare $47 million, which suggests telehealth and care coordination can reduce costs. CMMI continues its work with programs like Independence at Home, which supports care at home for frail seniors and often uses telehealth.
Artificial intelligence (AI) and workflow automation are becoming more important for running telehealth in ACOs. These tools can help with scheduling, patient communication, and clinical decision support.
Simbo AI is a company that offers phone automation and answering services using AI. It helps healthcare groups handle many patient calls. In ACOs, where talking to patients quickly is important, automating phone triage and appointments can lower work for staff and improve care access.
AI virtual assistants can check if patients are eligible for telehealth visits, send appointment reminders, and follow up after visits. These tools make workflows smoother, so clinical staff can focus more on patients than paperwork.
On the medical side, AI can monitor telehealth data, find patients at risk, and help providers make better care decisions. For chronic disease, AI can predict flare-ups before they happen, allowing early help through telehealth.
Using telehealth with AI tools supports care coordination goals in the CMS Shared Savings Program. It helps keep up with reporting, quality checks, and improves patient satisfaction with faster communication.
The Bipartisan Budget Act of 2018 set the stage for wider use of telehealth in ACOs and beyond. Even as some temporary pandemic-related flexibilities end, the permanent changes for telehealth access and patient incentives help care delivery progress.
Medical practice leaders and IT managers in ACOs should understand these policy changes. Adopting telehealth needs investments in technology, careful planning, and attention to rules and payments. Using AI tools like Simbo AI can make running telehealth programs easier.
With more patients wanting virtual care, changing CMS rules, and growing proof of telehealth’s value, ACOs that use telehealth and related technology can improve quality, engage patients better, and control costs in the future.
ACOs must have a designated compliance official, a detailed compliance plan in accordance with 42 CFR § 425.300, and comply with program requirements throughout the year.
It granted new flexibilities for ACO physicians to deliver telehealth services without geographic limitations for dates of service on or after January 1, 2020.
ACOs must provide beneficiaries with a Beneficiary Information Notification at their first primary care visit, detailing their participation in the Shared Savings Program and options available.
ACOs must provide a follow-up communication with beneficiaries after their first primary care visit, allowing discussion about ACO benefits and addressing any questions.
Beneficiary assignment is crucial for calculating an ACO’s financial benchmark, assessing financial performance, and determining samples for quality reporting.
ACOs must have at least 5,000 Medicare fee-for-service beneficiaries assigned and comply with CMS regulations, alongside maintaining accurate participant lists.
An ACO participant that bills Medicare for primary care services must be exclusive to one ACO; individual practitioners can join multiple ACOs under different TINs.
ACOs must maintain a dedicated webpage for public reporting of required organizational information and performance results, adhering to CMS’s reporting instructions.
ACOs must report quality data to CMS annually; participation in the Alternative Payment Model Performance Pathway is mandatory for quality performance assessment.
Providers delivering telehealth services must adhere to CMS guidelines regarding billing, geographic limitations, and use of originating sites for telehealth delivery.
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