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ACO Final rule released

November 16, 2011

Center of Medicare and Medicaid services released the final accountable care organization rule. ACO’s consist of physicians, hospitals, and other providers in various combinations that attempt to coordinate the care of Medicare patients with the goal of improving its quality while reducing costs. Successful ACOs would be entitled to share any savings they produce for Medicare on top of their usual fee-for-service reimbursements.

The rule contains numerous allowances aimed at lowering the cost and risk burdens for those looking to participate in the Medicare shared savings program. Following are few of the highlights in the final rule

  • A reduction to 33 ACO quality measures, as opposed to 65 in the earlier proposed ACO rule.
  • The elimination of downside risk which, as Healthcare Informatics points out, would have forced providers to pay back to Medicare the cost of unsuccessful savings efforts.
  • This rule works as an encouragement for the use of electronic health record, as a condition of ACO participation (though EHR use remains a quality measure)
  • The addition of federally qualified health centers, critical-access hospitals and rural health clinics as ACO participants and leaders, along with an advanced payment model that will dole out $170 million to help those who qualify get a head start
  • Patients will no longer be assigned to accountable care organizations retrospectively. Medicare enrollees will be assigned to ACOs prospectively, every three months, but the CMS will review assignments at the end of each year

Physicians group and other participant are positive about this Final ACO rule as the proposed rule was too strict and feared that its cumbersome IT requirements, complex application process, strict deadlines, excessive quality measures and high risk threshold would lead few organizations to actively participate.

With this final rule number of participants is believed to increase. CMS actuaries say that up to 270 groups could form an ACO; this is twice what actuaries said after the proposed rule’s release. Such participation could bring 2 million Medicare patients into the ACO model.

This definitely would increase the pressure on billing departments under ACO, wherein the quantum of billing tends to be usually large, but the fee is highly competitive. Hence these ACO’s would require highly skilled medical billers and coders to take care of their reimbursement cycle.

Medicalbillersandcoders.com (www.medicalbillersandcoders.com), the largest consortium of billers and coders in the U.S., anticipates the operational difficulty in such a scenario thus with its highly skilled and experienced medical billers and coders is combining its expertise to bill for ACOs in the coming times.


Category : ACA / HIPAA / Reforms