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.

• Shared Savings Model
• Savings Bonus Plus Penalty Model
• Capitation Model
• MACRA - Alternative Payment Models (APMs)

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.