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Healthcare provider reimbursement under Medicare Shared Savings Program

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In their press release dated June 6, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the adoption of a final rule that will encourage more physicians to improve patient care by joining Accountable Care Organizations.

This adjustment represents a shift in Medicare from paying for each service a physician provides towards a system that rewards physicians for coordinating with each other. “Accountable Care Organizations are a major part of that transition,” says CMS, “rewarding providers that deliver high-quality, efficient, and coordinated care for patients.”

All of the recent changes have been aimed at changing how the industry measures patient care and accountability.  This final rule takes aim at “also refining how the program measures success, so that current participants are better rewarded for quality,” said CMS Acting Administrator Andy Slavitt. “These new flexibilities are based on significant input from participants and will help physicians prepare for the new Quality Payment Program, part of bipartisan legislation Congress passed last year repealing the failed Sustainable Growth Rate.”

“Medicare bases Accountable Care Organizations’ payments on a variety of factors, including whether the Accountable Care Organization can deliver high-quality care at a reasonable cost,” CMS says. “The final rule should help more Accountable Care Organizations successfully participate in the Medicare Shared Savings Program by improving the shared savings payment methodology and providing a new participation option for certain Accountable Care Organizations to move to the more advanced tracks of the program.”

In the final rule, CMS is revising the approach for resetting (or rebasing) an ACO’s benchmark for a second or subsequent agreement period beginning on or after January 1, 2017.

Methodology changes

  • Replace the national trend factor with regional trend factors for establishing the ACO’s rebased historical benchmark and remove the adjustment to explicitly account for savings generated under the ACO’s prior agreement period.
  • Make an adjustment when establishing the ACO’s rebased historical benchmark to reflect a percentage of the difference between the regional FFS expenditures in the ACO’s regional service area and the ACO’s historical expenditures.
  • Annually update the rebased benchmark to account for changes in regional FFS spending, replacing the current update, which is based solely on the absolute amount of projected growth in national FFS spending.
  • Adjust an ACO’s rebased historical benchmark prior to the start of the performance year, including redetermining the regional adjustment, to account for changes in the ACO’s certified ACO Participant List during the agreement period.

More specifics are detailed in a fact sheet available on the CMS website.   For more information on the Medicare Shared Savings Program, please visit their information page on the CMS website.

Rev-Ignition delivers not only a Revenue Cycle Management (RCM) product and resource, we deliver a team of experts to partner with your office, working to maximize reimbursement for your services.  For more information, explore our website or call (844) 297-9944 to speak with one of our knowledgeable professionals today.