MSSP Final Rule Tweaks ACO Payment Model

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  • June 9, 2015
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The Centers for Medicare & Medicaid Services (CMS) finalized, June 4, a Medicare Shared Savings Program (MSSP) final rule that includes a provision relating to Accountable Care Organization (ACO) payment. It has been four years since the establishment of the ACO model, and this final rule provides general maintenance to keep things running smoothly.
The Medicare Shared Savings Program was established by section 3022 of the Patient Protection and Affordable Care Act of 2010; and a final rule, published in 42 CFR Part 425, implemented the provision on Nov. 1, 2011.
ACOs have taken off, since then. According to a Fast Facts on the MSSP website, as of January 2015 there are 404 MSSP ACOs and 19 Pioneer ACOs serving 7.92 million assigned beneficiaries in 49 states, plus Washington, D.C. and Puerto Rico.
The policies adopted in this latest final rule seek to reduce administrative burden and improve program function and transparency.
To that end, CMS is making the following major modifications to current program rules:

  • Clarifying and codifying current guidance related to ACO participant agreements and issues related to the ACO participant and ACO provider/supplier lists.
  • Adding a process for an ACO to renew its three-year participation agreement for an additional period.
  • Adding, clarifying, and revising the beneficiary assignment algorithm. Specifically, CMS is:
    • Updating the CPT codes that will be considered primary care services to include transitional care managment codes 99495 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge and 99496 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge; and the chronic care management code 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
    • Finalizing a policy that would use primary care services furnished by primary care physicians and other qualified healthcare professionals under step 1 of the assignment process, after having identified beneficiaries who received at least one primary care service by a physician in the ACO.
    • Revising how primary care services furnished in federally qualified health centers and rural health clinics are considered in the assignment process.
  • Expanding the kinds of beneficiary-identifiable data that will be made available to ACOs in various reports under the MSSP, as well as simplifying the process for beneficiaries to decline claims data sharing;
  • Adding or changing policies to encourage greater ACO participation in risk-based models, by:
    • Permitting ACOs to participate in an additional agreement period under one-sided risk with the same sharing rate (50 percent);
    • Giving ACOs the choice of several symmetrical minimum loss rate/minimum savings rate options that will apply for the duration of its 3-year agreement period under Track 2.
    • Offering ACOs an option to participate under a (Track 3) two-sided risk that would incorporate a higher sharing rate (75 percent), prospective assignment of beneficiaries, and the opportunity to apply for a programmatic waiver of the 3-day skilled nursing facility (SNF) rule.
  • Resetting the benchmark in a second or subsequent agreement period by integrating previous financial performance and equally weighting benchmarks for subsequent agreement periods.
  • Waiving (under part 425) the requirement for a 3-day inpatient hospital stay prior to the provision of Medicare covered post-hospital extended care services for beneficiaries who are prospectively assigned to ACOs that participate in Track 3. This waiver will be effective on or after Jan. 1, 2017.

CMS said it also anticipates a telehealth waiver for ACOs, no earlier than Jan. 1, 2017.
See Table 1 in the final rule for applicability and effective dates of select provisions.
For the full text, see the final rule in the Federal Register.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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