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Frequently Asked Questions

Part 1:          General Questions:

 Question #1:            What is an Accountable Care Organization (ACO)?

Answer:         An Accountable Care Organization (ACO) is traditional Medicare with a focus on quality care and providing information to Providers to use in developing chronic care plans and coordinating with other providers using complete medical and historical data to target special beneficiary needs.  An ACO is a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in beneficiary care) that work together to coordinate care for the Medicare Fee-For-Service beneficiaries they serve. The goal of an ACO is to deliver seamless, high-quality care for Medicare beneficiaries, instead of the fragmented care that often results from a Fee-For-Service payment system in which different providers receive different, disconnected payments. The ACO will be a beneficiary-centered organization where the beneficiary and providers are true partners in care decisions.


Question #2:            How is an ACO paid for and paid by whom?

Answer:         Medicare will continue to pay individual providers and suppliers for specific items and services as it currently does under the Medicare Fee-For-Service systems. CMS will develop a benchmark for each ACO against which ACO performance is measured to assess whether it qualifies to receive shared savings, or for ACO’s that have elected to accept responsibility for losses, potentially be held accountable for losses. The benchmark is an estimate of what the total Medicare Fee-For-Service Parts A and B expenditures for ACO beneficiaries would otherwise have been in the absence of the ACO, even if all of those services were not provided by doctors in the ACO. The benchmark will take into account beneficiary characteristics and other factors that may affect the need for health care services. The benchmark will be updated for each performance year within the agreement period.

CMS is implementing both a one-sided model (sharing savings, but not losses, for the entire term of the first agreement) and a two-sided model (sharing both savings and losses for the entire term of the agreement), allowing the ACO to opt for one or the other model for their first agreement period. CMS believes this approach will have the advantage of providing an entry point for organizations with less experience with risk models, such as some physician-driven organizations or smaller ACOs. This will allow them to gain experience with population management before transitioning to a shared losses model, while also providing an opportunity for more experienced ACOs that are ready to share in losses to enter a sharing arrangement that provides a greater share of savings, but with the responsibility of repaying Medicare a portion of any losses.

CMS will establish a Minimum Savings Rate (MSR) and a Minimum Loss Rate (MLR) to account for normal variations in health care spending. The MSR is a percentage of the benchmark that ACO expenditure savings must meet or exceed in order for an ACO to qualify for shared savings in any given year. Similarly, an ACO with expenditures at or above the MLR will be accountable for repaying shared losses. Under the final rule, ACOs in the one-sided model that have smaller populations (and having more variation in expenditures) will have a larger MSR and ACOs with larger populations (and having less variation in expenditures) have a smaller MSR. Under the two-sided model, CMS will apply a flat 2 percent MSR to all ACOs.

Under both models, if an ACO meets quality standards and achieves savings and also meets or exceeds the MSR, the ACO will share in savings, based on the quality score of the ACO. ACOs will share in all savings, not just the amount of savings that exceeds the MSR, up to a performance payment limit. Similarly, ACOs with expenditures meeting or exceeding the MLR will share in all losses, up to a loss sharing limit.


Question #3:            Is this a replacement for the Medicare Advantage Plans?

Answer:         No, an ACO is a group of doctors, hospitals, and other health care providers who work together to provide Medicare beneficiaries with better, more coordinated care. Doctors and hospitals in an ACO communicate with their patients and with each other to make sure their patients get appropriate care when sick, or to stay healthy and well.

An ACO is not an HMO, managed care plan, Medicare Advantage or an insurance plan. Unlike HMOs, managed care, Medicare Advantage or insurance plans, an ACO cannot tell a Medicare beneficiary which health care providers to see nor can it change Medicare benefits. If a doctor participates in a Medicare ACO, their patients always have the right to choose any doctor or hospital who accepts Medicare at any time.


Question #4:            Is there a “preferred” network for ACOs that do not have an affiliation with a hospital? 

Answer:         The ACO may determine a "preferred network" of providers/suppliers that the ACO wishes to use for referrals.  However, such network may not be presented to a beneficiary as a limitation on their choice of providers.  The beneficiary always has the right to choose their provider.


Question #5:            Will ACO materials and updates be provided to the ACO in a 3-ring binder where updates can be added as necessary?  What does this encompass?

Answer:         ACO materials created internally or via CMS direction will be distributed to the ACOs in advance of delivery to participants and/or beneficiaries.  Initially, distribution methods to the local ACOs will be via the Network Management staff.


Question #6:            If chairman of a committee cannot attend can he designate someone to serve in that capacity for a specific meeting? Does it have to be a voting member?

Answer:         Yes the Chairman may designate a replacement but that individual would need to be a voting member of the Management Committee. 


Question #7:            Do non-voting committee members count in quorum calculation?

Answer:         Yes non-voting members count in meeting quorum requirements, but they are not allowed to vote. 



Part 2:          Beneficiary Questions:


Question #8:            Can a beneficiary continue to self-refer to a specialist?

Answer:         Yes, the beneficiary's may self-refer. Choice is never limited for the beneficiary.


Question #9:            Is there a “Do Not Contact List” which allows beneficiaries to request no further phone calls or contact from the ACO?

Answer:         Yes, a beneficiary has the opportunity to request not to be contacted again.  The beneficiary’ name and request will be logged in the system and no further contact will be initiated.  However, the ACO still has the responsibility for the care and quality of the beneficiary.


Question #10:          Will the physicians know which beneficiaries are classifies as high-risk; and what if the physician disagrees with that classification? 

Answer:         Yes ACO physicians will receive a listing from CHS showing high risk patients.  If there are discrepancies the physician will discuss with the care manager. 



Part 3:          Care Coordination Questions:

Question #11:          What process will Care Coordination use to recommend services for patients to the provider?

Answer:         When the Care Coordinator identifies needs for services to improve the patient’s care and/or health, he/she will communicate with the appropriate provider in order to request and facilitate a referral.



Part 4:          Data Feed Questions:

Question #12:          What is the process to receive claims data from CMS when the ACO has difficulty with specific physician offices and NPI # fields as we prepare for the Opt-Out process?

Answer:         The first and most vital step is for CHS and field personnel is to work together with ACOs and physician offices to get correct and complete after address information. A complete Opt-Out mailing cannot be run without both pieces of information.  Relative to working with CMS on those beneficiaries with inadequate information we have yet to get that far in the process but will inform all associates once a suitable game plan has been established.


Question #13:          How will the quarterly beneficiary roster update process work? 

Answer:         ACO participants will receive a quarterly roster of assigned beneficiaries.


Question #14:          If there is a discrepancy between the CMS beneficiary file data and that within the doctor’s office what can be done to correct it?

Answer:         Currently, CMS does not have a process to address discrepancies between their beneficiary identification information (i.e. HICN) and the data within a doctor's office. We will defer to CMS' data until such time a tool becomes available to address discrepancies.



Part 5:          Governing Body Questions:

Question #15:          In the absence of the Chairman, could an outside person serve as Chair?

Answer:         The “Rules of Order “delineate that in the absence of the Chairperson, the descending order of who should Chair is:

1)        The Vice Chairperson;

2)        The most Senior Vice President (not particular order); then

3)        A Vice President.                                                                

If the Chairperson must leave during a meeting, the Chair may, subject to the approval of the Committee, appoint a Chairperson Pro Tempore, to serve as Temporary Chair.

The Chairperson, knowing that s/he will be absent from future meetings, cannot in advance authorize another member to preside in his/her place.

If the Chairperson is present, but must leave, the Secretary should “Call meeting to order” and then proceed to elect a Chairperson Pro Tempore (This assumes a quorum has been met.).

In very limited circumstances, an invited Temporary Chair may be used (i.e. for a matter which intensely divides an organization and requires the regular Chair to participate in the debate).



Part 6:          Implementation Questions:

Question #16:          Is the Attestation document required to be signed by all in the ACO group? 

Answer:         The Attestation was a document created by CHS to ensure that the Participants are aware of and committed to the ACO.  Due to changes in the filing process this document is no longer needed and doctors do not need to sign it.   


Question #17:          What are the new requirements on the application for the narratives on the physicians?

Answer:         The January 2013 ACO Application includes a new narrative on the history of the ACO.  As part of this history, we desire to include several sentences on each of the key (larger) Participants of that ACO.  This could include a brief overview of the number of years in practice, sub specialties, philosophical directions or dedication to the community they serve.



Part 7:          Medical Data Questions:

Question #18:          How will beneficiaries’’ medical data be shared or obtained from practices not in the ACO and also referral hospitals and ancillaries?

Answer:         The data will be obtained in several ways; through CMS provided claims data, existing physician EMR systems and third party claims sources.


Question #19:          How current will the beneficiaries’’ medical data be to help avoid duplication of services like lab work or diagnostic imaging? 

Answer:         The data will provide information from sources which the ACO provider may not have current access. As such the physician will be able to see labs or services ordered by other care providers.  This should allow the physicians to request/or not request additional test/labs based on patient needs. 


Question #20:          Will ACOs be notified prior to a beneficiary receiving a visit or phone call from Care Coordinators. This would allow ACOs to be prepared to answer any questions the beneficiary may have?  Will this notification be prior to the Opt-Out letters or PHA mailings? 

Answer:         ACO participants and their staff will be trained prior to the distribution of materials to beneficiaries.  Care Coordination contacts will be conducted as needed, based on the care plan/needs of the beneficiary.  The Care Coordination team will ensure that the PCP and/or appropriate physician(s) are involved in such discussions/treatment plans.


Question #21:          Will the ACO process help me to get better notification when my patients are in referral hospitals not tied to the ACO?

Answer:         Each ACO will be developing a communication platform to aide in the timely notification of clinical events. The care coordination team will be engaging with the various facilities being utilized by the beneficiaries to support the notification process.  In addition, the ACO will continually analyze the data received from CMS and/or providers to ensure that all appropriate facilities are included.


Question #22:          How will we report on the Quality Indicators and what type of reporting will I see from that?

Answer:         The 33 Quality Measures fall into four reporting categories: 1) Claims, 2) EHR Incentive Program, 3) Patient Survey and, 4) GPRO Web Interface/Tool.  The ACO will be responsible for collecting and reporting on those measures falling under the GPRO category.  CMS will be releasing the process for the GPRO reporting in late 2012.


Question #22:          Will the beneficiary’s implicit agreement to share their medical data negate the requirement of HIPAA release forms to get data from a referral hospital?

Answer:         To better treat patients and to coordinate their care ACOs will be able to request CMS Medicare claims information on their patients. ACOs must notify a beneficiary in writing that their  claims information is being requested from CMS. ACOs must allow beneficiaries to decline having their claims information shared with the ACO. Declining to have this information shared, however, does not affect the provider’s participation in the ACO or CMS’ use of the patient’s data for the purpose of assessing ACO’s performance on quality or cost measures. This notification may happen by mail but must also happen the first time an ACO practitioner provides a primary care service to the beneficiary.



Part 8:          Opt-Out Questions:

Question #23:          If the ACO list of provider/suppliers associated with the Participant TIN in the Shared Savings Program Application did not include mid-level practitioners, for opt-out mailing purposes can the ACO use the name of an NP, PA, or Group providing care under the Participant TIN?

Answer:         CMS has indicated that the ACO look back at list again and verify what TIN the beneficiary is assigned to as all beneficiaries must have a primary care physician. .



Part 9:          Provider Handbook Questions:

Question #24:          In the Provider Handbook, Appendix B, Page 38, should there be criteria for an annual eye exam for Diabetics?

Answer:         Each quality measure includes narrative specifications, as defined by the National Quality Foundation (NQF).  These descriptions delineate the population, exclusions and rationale for the measure.


Question #25:          What does the “transfer of care” mean; or how do we identify a patient is referred or transferred to the ER, Urgent Care Specialist, when the care could be done at the PCP office?

Answer:         Each ACO will develop a communications platform to aide in the timely notification of clinical events.  This notification process will provide triggers for Care Coordination team to intervene at the appropriate time/place to ensure adequate support for the beneficiary and their care giver.


Question #26:          Two doctors wanted to know if there are Critical Pathways established for the chronic conditions like diabetes, CHD, COPD?

Answer:         Each ACO will develop a Care Coordination plan as well as a quality improvement plan.  Both of these plans will include the use of clinical pathways/guidelines as agreed upon by the Management Committee of the ACO.


Question #27:          How will a patient’s refusal to take a preventive test (i.e. colonoscopy) be rated?  Will it count against the ACO?

Answer:         Patients have the right to refuse treatment at any time.  At the same time, the ACO has the responsibility to manage the care of the assigned beneficiaries and report the results to CMS through the established quality measures.  In those situations where a patient has refused treatment, the ACO will be required to report it as such and the measure will not be considered met.


Question #28:          Can the PCPs get copies of the PHAs for their patients?

Answer:         The care coordination team maintains copies of all assessments and can provide such documentation to any provider that requests.


Question #29:          Can PCPs get a list of their attributed patients?

Answer:         Quarterly beneficiary rosters will be provided to each PCP.


Question #30:          Is CMS using current wellness guidelines?  Screening recommendations have not been updated in NextGen (i.e., Question 12 on PHA indicates that Pneumonia Vaccination is every 5 years – it is actually one vaccination at age 65 for a healthy patient and one vaccination when chronic patient is diagnosed, then one after five years later and one again five years after that).

Answer:         Each quality measure includes narrative specifications, as defined by the National Quality Foundation (NQF).  These descriptions delineate the population, exclusions and rationale for the measure.



Part 10:       Reporting Questions:

Question #31:          How will the Quality Indicators be reported?  What type of reporting will be provided on the report? 

Answer:         The 33 Quality Measures fall into four reporting categories: 1) Claims, 2) EHR Incentive Program, 3) Patient Survey and, 4) GPRO Web Interface/Tool.  The ACO will be responsible for collecting and reporting on those measures falling under the GPRO category.  CMS will be releasing the process for the GPRO reporting in late 2012.



Part 11:       TIN Questions:

Question #32:          Is it required to have one Provider Agreement per TIN, or one Provider Agreement per participating physician?

Answer:         One TIN per Provider Agreement is required.


Question #33:          The application requires that the Applicant submit information and documentation relating to TINs that have been subsumed through a merger or acquisition.  Does CMS want the same information on TINs that have been subsumed via other means (e.g. bankrupt ACO Participant joins a health system or medical group)?

Answer:         Only TINs by merger or acquisition are to be identified and reported to CMS.


Question #34:          What is the CMS acceptable methodology to add, delete or alter TINs information from what was originally submitted to CMS?

Answer:         At this point in time CMS has acknowledged that more specific and detailed TIN rules and guidance is needed and will be forth coming but is not yet complete.   As soon as CHS has received new CMS procedures regarding TIN changes it will be distributed to all.


Question #35:          How will an addition to a TIN of an existing ACO be communicated internally and externally?

Answer:         This process is being worked on at this time.  CMS guidance is needed here as well.  When we have the process finalized it will be distributed to all.


Question #36:          Will any data be provided on deceased beneficiaries?  What is the process if the beneficiary expires after the CMS list is compiled?

Answer:         We will not be sending an Opt-Out letter to deceased beneficiaries and will not need information on deceased beneficiaries.


Question #37:          Why might there be a discrepancy between the listing of attributed members from CMS and that from the physician?

Answer:         The most common reason for lower than expected beneficiary counts within a TIN is due to plurality of care. Beneficiaries will be attributed to the ACO participant providing the most primary care services. Other reasons FFS beneficiaries might not have been attributed include time spent in a MA plan or not having both parts A&B coverage.


Question #38:          Will a list of beneficiaries attributed to each doctor and practice be provided to the Executive Directors? 

Answer:         Currently this is not a planned ongoing service. Nevertheless, where needed any by request and agreement between the ED and CHS Operations such a request will be fulfilled.

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