From eligibility and guidelines to strategies and payment, know everything you need to build your Accountable Care Organization.
Become ACO Ready
The following groups of providers and suppliers of Medicare-covered services are eligible to form an ACO:
Any Medicare-enrolled provider or supplier may join an ACO formed by the entities identified above. Any Medicare provider or supplier in good standing is encouraged to participate in an ACO since all health care providers are important for the ACO to achieve its goal of better coordinating care. However, providers and suppliers who are already participating in another program or initiative involving shared savings under Fee-For-Service Medicare are not eligible to participate in a Shared Savings Program ACO.
If an ACO is formed by more than one provider or supplier, the ACO must be a legal entity separate from the providers or suppliers that formed it. An ACO formed by a single Medicare provider or supplier need not form a separate legal entity to participate in the Shared Savings Program as an ACO, as long as it satisfies the same organization and governance requirements applicable to all ACOs.
To participate in the Shared Savings Program, eligible providers and suppliers must form a Medicare ACO, and the ACO must apply to CMS. An existing ACO will not be automatically accepted into the Shared Savings Program. To be accepted, ACOs must serve at least 5,000 Medicare Fee-For-Service patients, meet all other eligibility and program requirements, and agree to participate in the program for at least 3 years.
The statute and program regulations specify the eligibility and program requirements. For example, each ACO is required to establish a governing body that includes a Medicare beneficiary and provides ACO participants with meaningful participation in ACO governance. In addition, the ACO is responsible for developing processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost measures, and coordinate care. The ACO is responsible for maintaining a patient-centered focus.
ACO’s success depends on the physicians. A team of physicians with access to real-time data and a working knowledge of analysis methodologies, which will lead to engaged providers and improved physician buy-in.
Invest in an IT infrastructure which will help in Clinical, Claims, Immunization, Billings, Labs, and Pharmacy Data Integration and link unstandardized information from disparate systems to create a comprehensive Master Patient View.
Value-Based Performance Analytics to track all payer contracts by quality and cost measures, with drill-down by region, facility, and providers and comparison view which allows you to identify improvement opportunities to beat benchmarks.
Leverage Cost Driver Analysis to identify and manage key drivers of costs in the network across disease categories, facilities, and providers to optimize costs. Perform Network Leakage & Utilization Analysis to understand and optimize revenue leakages throughout the network
Care Management that empowers health coaches to stratify chronically ill and high-risk population, identify their gaps in care, design optimal care plans and interventions, take action supported by utilization review and disease management.
Care transitions account for a significant portion of wasteful spending. By managing care transitions, providing accountability, and comprehensively documented information, develop a more intensive care management approach. Close the care loop by connecting with patients post-acute episode.
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