ACO Proposed Rule Review: Part 8

Page references refer to the version of the rule found at:  Today’s installment has been extracted from page 139-165.

IID—Assignment of Medicare Fee-for-Service Beneficiaries (attribution methodology)

Attribution methodology assigns patients based on the physician who provided a plurality of primary care services (general practice, family practice, internal medicine and geriatric medicine).  Note:  for PAs and NPs who see a patient for their primary care visits, in states like NC, should we consider proposing to CMS the patient get assigned based on the PAs or NPs supervising or collaborating physician? 

 Assignment refers to an operational process by which Medicare will determine whether a beneficiary  has chosen to receive a sufficient level of the requisite primary care services from physicians associated with a specific ACO so that the ACO may be appropriately designated as exercising basic responsibility for the beneficiary’s care.  Assignment, however does NOT limit, restrict, or diminish the rights of Medicare FFS beneficiaries to exercise complete freedom of choice in the physicians and other health care practitioners and suppliers form whom they receive their services.

  1. Operational Identification of an ACO:
  • Organizations applying to be an ACO would have to provide their ACO participants TINs (because TINs are linked to an individual physician specialty code).    So beneficiaries would be assigned to an ACO through a TIN based on the primary care services they received from physicians billing under that TIN.
  • ACO professionals within the respective TIN on which beneficiary assignment is based, will be exclusive to one ACO agreement in the Shared Savings Program (SSP). (Note:  According to CMS, this exclusivity will only apply to the PCP by whom beneficiary assignment is established.)
  • PCPs whom assignment is dependent would be committed for a 3-year period and be exclusive to one ACO.  To ensure that physicians and other entities upon which assignment is not dependents (e.g., specialists, hospitals, FQHCs, RHCs) can participate in more than one ACO and thereby facilitate the creation of competing ACOs, these providers and suppliers also would be committed to the 3-year agreement but would not be exclusive and would have the flexibility to join another ACO.
  • Organizations applying to become an ACO must provide not only their TINs but also a list of associated NPIs for all ACO professionals, including a list that separately identifies physicians that provide primary care. 
  • CMS seeks comments on the proposal to require reporting of TINS along with information about the NPIs associated with the ACO. 

2. Definition of Primary Care Services

  • Beneficiaries would be assigned with physicians designated as PCP providers (FP, IM, GP, geriatric medicine) who are providing the appropriate primary care services to beneficiaries (defined on the basis of the select set of HCPCS codes identified in 5501 of the Affordable Care Act, including G-codes associated with the annual wellness visit and Welcome to Medicare visit..
  • CMS invites comments on other options that may better address the delivery of primary care services by specialists (please see pages 147-153 for other options that CMS considered).

3. Prospective vs. Retrospective Beneficiary Assignment to Calculate Eligibility for Shared Savings

  • Beneficiaries will be assigned using a combined approach of (a) retrospective beneficiary assignment for purposes of determining eligibility for shared savings balanced by (b) the provision of aggregate beneficiary level data for the assigned population of Medicare beneficiaries during the benchmark period.
  • CMS seeks comments on the combined approach of retrospective beneficiary assignment for purposes of determining eligibility for shared savings balanced by the provision of beneficiary data and aggregate beneficiary level data for the assigned population during the benchmark period. 
  • CMS also seeks comments on alternate assignment approaches, including the prospective method of assignment. 

4. Majority vs. Plurality Rule for Beneficiary Assignment

  • Beneficiaries would be assigned, for purposes for the SSP, to an ACO if they receive a plurality of their primary care services from primary care physicians within that ACO.
  • A plurality of allowed charges for primary care services would be used for beneficiary assignment.
  • CMS seeks on proposal using a plurality vs. a majority of primary care visits.  Also should there be a minimum threshold number of primary care services that a beneficiary should receive from physicians in the ACO in order to be assigned to the ACO under the plurality rules and if so, what should that minimum be?

5. Beneficiary Information and Notification—CMS intends to develop a communications plan, including educational materials and other forms of outreach, to provide beneficiaries in a timely manner with accurate, clear, and understandable information about the SSP in general, about their utilization of services furnished by a provider or supplier participating in an ACO, about the possibility of their being assigned to an ACO for quality and shared savings purposes, and about the potential that their health information may be share with the ACO, and their ability to opt-out of that data sharing. 

  • ACOs would be required to post signs in the facilities of participating ACO providers/suppliers indicating their participation in the SSP and to make available standardized written information to Medicare FFS beneficiaries whom they serve.
  • ACOs would provide standardized written notice to beneficiaries of both their participation in the SSP and the potential for CMS to share beneficiary identifiable data with ACOs when a beneficiary receives services from a physician on whom assignment to ACO is based.
  • ACOs will be required to provide a form allowing beneficiaries to opt-out of having their data shared. The form would be provided to each beneficiary as part of their office visit with a primary care physician, and must include a phone number, fax, or email for beneficiaries to contact and request that their data not be shared. 
  • ACO would be required to provide beneficiaries notice in a timely manner if they will no longer be participating in the SSP, which should include the effective date of the termination of their agreement with CMS.  (Note: does this mean they would have to send the info out to the beneficiaries or provide such notice to beneficiaries that come in for a visit within a certain amount of time?)
  • ACOs seeking to terminate its participation in the SSP would be required to provide CMS with advance notice.
  • Note:  This notice to beneficiaries, especially regarding termination, seems over the top since beneficiaries aren’t restricted as to where they can seek care, and the information is would be included in the Medicare Handbook.
  • CMS seeks comment on the appropriate form and content of this notification, e.g., on the utility of informing consumers about those objectives of the SSP that might have the most impact on the beneficiary as a consumer of services from an ACO professional such as:
    •  Easing the burden on consumers to coordinate their own care among different providers, 
    • Fostering follow-up with patient as they receive care from different providers,
    • Facilitating great dialogue between and among beneficiaries and providers about how health care is delivered, and
    • Providing beneficiaries what quality measures by which they can evaluate the performance of their providers compared to regional and national norms. 

                                                                         v.      CMS also seeks comments on the most import items to communicate to beneficiaries about matters that will not change under the SSP, including the fact that their cost-sharing will continue to be the same, and they remain free to seek care f4rom providers of their choosing.

                                                                       vi.      If a notification requirement is adopted in the final rule, CMS would like to know what the appropriate form and content of such a notification should be ….


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