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Accountable Care Organization Requirements

  • Affordable Care Act Requirements

    ACOs eligible for the Medicare Shared Savings Program (MSSP) under the Affordable Care Act (ACA) of 2010 must meet the following criteria:

    • Have established structures for reporting quality and cost of health care, leadership, and management that include clinical and administrative systems, receipt and distribution of shared savings, and shared governance;
    • Be willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it;
    • Have a minimum three-year contract;
    • Have sufficient primary care physicians and providers to have at least 5,000 patients (Medicare fee-for-service beneficiaries) assigned;
    • Have processes to promote evidence-based medicine, patient engagement, and coordination of care; and
    • Be able to demonstrate patient-centeredness criteria, such as individualized care plans.

     

    The 2015 Medicare final rule and three other related documents involving five federal agencies amplify these ACA requirements.

  • ACO Payment

    What are the types of financial incentive models for ACOs?

    There are three tiers: upside-bonus-only shared savings, a hybrid of limited-upside and limited-downside shared savings and penalty, and full-upside and full-downside capitation.

  • What are key legal issues affecting ACOs?

    ACOs require collaboration, referrals, reductions in unnecessary care, and sharing of revenues among sometime competitors.

    A properly configured ACO should be successful in navigating this legal minefield. The principal bodies of law affecting ACOs are:

    • Antitrust,
    • Antikickback,
    • Stark,
    • Civil monetary penalties,
    • Tax,
    • HIPAA,
    • Malpractice,
    • Corporate practice of medicine,
    • Insurance,
    • Intellectual property,
    • State self-referral, and
    • Business.
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  • ACO Regulations, Payment, and Compliance