An ACO is a group of doctors, hospitals, and other healthcare providers who choose to work together to give coordinated care to their Medicare patients. The goal is to help patients get better care and keep healthcare costs down. Unlike Medicare Advantage plans, patients in an ACO can still see any doctor they want, even those not in the ACO.
The Medicare Shared Savings Program encourages ACOs to reduce healthcare costs and meet certain quality standards. If ACOs do well, they can share in the money saved for Medicare. But to join, ACOs have to follow strict program rules, including rules about compliance and involving patients.
To be part of the program, an ACO must have at least 5,000 Medicare fee-for-service patients assigned each year. Patients are usually assigned based on where they get most of their primary care. The number of patients and how they are assigned affect the budget and savings calculations.
ACOs can include different types of healthcare providers like group practices, hospitals, and clinics. The program requires that the primary care doctors in an ACO bill Medicare only under one Taxpayer Identification Number (TIN) during the year.
ACOs must be official legal groups allowed by state law to receive and distribute shared savings payments. Each ACO needs a governing body that oversees the group’s work, sets plans, and makes sure they follow program rules.
The leadership group can look different among ACOs, but it must have the power to carry out ACO duties. It should also include both healthcare providers and Medicare patients to represent everyone’s interests.
CMS requires every ACO to have a formal compliance program. This means naming a person to watch over the group’s adherence to program rules all year. The compliance plan must follow legal regulations and be updated every year.
The program includes regular checks, quick fixing of problems (usually within 60 days), training staff on legal and ethical rules, and protecting privacy for anyone reporting issues. ACOs must check every month that their providers are not on federal exclusion lists like LEIE or SAM, to avoid working with banned providers.
Failing to follow CMS rules can lead to fines, penalties, or being removed from the Shared Savings Program.
ACOs must report quality data to CMS every year to earn shared savings. Quality is measured using the Alternative Payment Model Performance Pathway (APP), which makes reporting simpler.
Quality measures include patient safety, coordinated care, preventive health, and patient experience. How well an ACO performs on these measures affects whether it can earn money or avoid losses. CMS also wants ACOs to keep improving care, staff skills, and patient health.
To keep patients informed and build trust, CMS requires ACOs to have a webpage where they share information like financial results, quality scores, compliance status, and program participation.
Regular and accurate public reporting helps patients and others make informed choices and holds ACOs responsible for how they perform.
Patient-centered care is very important in this program. ACOs must tell Medicare patients that they are part of an ACO at their first primary care visit. This notice explains what the program means for their care, any data sharing, and their right to accept or refuse participation.
After this first notice, ACOs must follow up within 180 days. This follow-up talks about program benefits, answers questions, and encourages patients to take part in their care. Good patient engagement can improve satisfaction and health, and it can also help the ACO financially.
ACOs in the Shared Savings Program choose from different risk levels. The BASIC track starts with sharing savings only and moves to more financial risk over time. The ENHANCED track has more risk but can earn higher savings.
At each year’s start, CMS assigns patients to each ACO and sets financial targets. These targets are spending goals that the ACO must manage to get incentive payments. Correct patient assignment helps CMS set fair targets and measure financial results.
ACOs must have a way to pay back losses if spending goes over targets. This makes sure ACOs are responsible for their costs.
Since January 1, 2020, the Bipartisan Budget Act lets some ACO providers, especially those in risk tracks, offer telehealth services without usual location limits. This helps ACOs provide care through telemedicine, especially to people in rural or underserved areas.
Telehealth billing still needs to follow CMS rules about where and how services happen. Providers must know about laws like HIPAA and state telehealth rules.
Because compliance is complex, technology helps ACOs manage tasks and lower the chance of mistakes. Artificial Intelligence (AI) and automation tools are getting more important in meeting CMS rules.
Medical practice leaders involved in or thinking about joining an ACO need to fully understand these rules. They should build strong governance and compliance systems, train staff regularly, and report data on time and accurately.
IT managers have an important role in setting up and maintaining systems for data, reporting, and communication so the ACO stays compliant with CMS changes. Using AI and automation tools can ease work and improve accuracy in compliance tasks.
Managing participation in the Medicare Shared Savings Program needs close teamwork among clinical, administrative, compliance, and IT staff. Each team helps the ACO meet CMS goals for low-cost, quality care and financial rewards.
Accountable Care Organizations in the Medicare Shared Savings Program follow clear rules to improve care coordination and control costs. They must meet eligibility, legal, governance, quality, patient engagement, and financial rules to succeed. Telehealth rules and new technology like AI and automation help ACOs manage these tasks.
Medical practice leaders in the United States should carefully check their readiness for these demands and invest in technology that supports long-term participation and performance in the program. This can help improve care while following federal goals for affordable healthcare spending.
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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