What is the primary goal of the Medicare Shared Savings Program?
Provide high-quality, coordinated care to improve outcomes and reduce costs. That’s the primary goal of the Medicare Shared Savings Program (MSSP).
How will Medicare reimbursement change for split/shared visits?
For 2023, split/shared visits must be billed under the NPI of the individual who provides more than 50% of total visit time. These new rules could significantly impact Medicare reimbursement for physician practices that use NPPs in facility settings.
How do you write a Medicare split/share claim?
The claim should include the modifier defined by Medicare to describe the visit as split/shared. Documentation in the medical record must identify the two individuals who performed the visit. The individual who performed the substantive portion must sign and date the medical record.
What changes did CMS make to the shared savings program?
On April 30, 2020, CMS made changes to the Shared Savings Program to give the 517 ACOs serving more than 11 million beneficiaries greater financial stability and predictability during the coronavirus disease 2019 (COVID-19) pandemic.
What is a shared savings payment model?
ABSTRACT: Shared savings is a payment strategy that offers incentives for providers to. reduce health care spending for a defined patient population by offering them a percentage of net savings realized as a result of their efforts.
How does ACO shared savings work?
The financial side of an ACO Another similarity between shared savings and bundled payments is that if the provider spends below the target amount, they can share in a portion of the savings. But if the provider spends above the target, they're financially responsible for covering the difference.
How are ACO benchmarks calculated?
The benchmark is based upon adjusting each benchmark year to BY3 and blending each benchmark year into a composite per capita target. The benchmark can also be adjusted based on the BY3 expenditure levels in the ACO's region—this is called the regional FFS adjustment.
What happens if an ACO meets quality targets for less than the payment?
If the ACO meets its targets for less than the payment, it keeps the difference. Depending on the type of contract, ACOs can be responsible for any difference beyond the predetermined amount required to meet its quality targets. There are a variety of risk contracts ACOs can negotiate with payers.
Can providers participate in multiple ACOs?
However, individual practitioners, identified by individual National Provider Identifiers (NPIs), are free to participate in multiple ACOs if they bill under several different TINs.
How do bundled payments work in healthcare?
A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test, or procedure.
How does Medicare determine which patients will be assigned to the ACO?
Under the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO), beneficiaries will be automatically assigned based on where they receive their primary care.
What type of spending is included in ACO benchmarks?
Under the MSSP, ACO financial benchmarks during the first contract period are based on three years of historical spending on assigned beneficiaries. Then, CMS trends forward the weighted and risk-adjusted average spending for those three years to account for the national average Medicare spending growth.
What is CMS benchmark?
Quality performance benchmarks are established by the Centers for Medicare & Medicaid Services (CMS) prior to the reporting period for which they apply and are set for two years. This document defines and sets the quality performance benchmarks that will be used for the 2020 and 2021 performance years.
What part of a patient's care is an ACO financially accountable for?
ACOs take value-based reimbursement to a new level by not only tying payments to quality, but also holding providers financially accountable for the care costs of their patient population.
What is the difference between CIN and ACO?
Although both ACOs and CINs are collaborative entities with similar goals, are are significant differences in the way they are structured. While an ACO is a contract-based term with payment tied to outcomes, a CIN is the organizing body that can support multiple contracts.
What is the difference between an ACO and an IPA?
ACO means Accountable Care Organization, formed by a group of doctors or hospitals to improve healthcare delivery to Medicare patients. An IPA or independent physician association helps doctors negotiate better terms with insurance companies.
What is shared savings?
The Shared Savings Program is an important innovation for moving the Centers for Medicare & Medicaid Services' (CMS') payment system away from volume and toward value and outcomes. It is an alternative payment model that: 1 Promotes accountability for a patient population. 2 Coordinates items and services for Medicare FFS beneficiaries. 3 Encourages investment in high quality and efficient services.
When does the ACO share savings program start?
The following table summarizes participation options under the BASIC track and ENHANCED track for agreement periods of at least five years, beginning on July 1, 2019, and in subsequent years.
What is Medicare ACO?
The Medicare Shared Savings Program (Shared Savings Program) offers providers and suppliers (e.g., physicians, hospitals, and others involved in patient care) an opportunity to create an Accountable Care Organization (ACO). An ACO agrees to be held accountable for the quality, cost, and experience of care of an assigned Medicare fee-for-service ...
What is the purpose of Medicare program intersection?
Program Intersection. There are several Medicare initiatives that aim to promote quality improvement while lowering the growth in health care expenditures. Although these programs are separate and distinct, they interact in key areas. The following programs intersect with the Shared Savings Program.
How many FFS beneficiaries are needed for ACO?
ACOs must have at least 5,000 Medicare fee-for-service (FFS) beneficiaries assigned to their ACO in each benchmark year to be eligible for participation in the Shared Savings Program. For Shared Savings Program ACO locations and contact information, refer to Program Data. For more information on eligibility criteria, ...
Can I participate in multiple ACOs?
However, individual practitioners, identified by individual National Provider Identifiers (NPIs), are free to participate in multiple ACOs if they bill under several different TINs.
How much Medicare Part B do you have to pay for incentive payments?
To be eligible for incentive payments under MIPS, physicians must receive 25% of their Medicare Part B payments or see 20% of their patients through the advanced APM.
What is MSSP in healthcare?
Medicare Shared Savings Program (MSSP) Provide high-quality, coordinated care to improve outcomes and reduce costs. That’s the primary goal of the Medicare Shared Savings Program (MSSP). The MSSP is an alternative payment model in which eligible providers, hospitals, and suppliers are rewarded for achieving better health for individuals, ...
Is an ACO higher than MSSP?
In other words, the ACO’s actual costs will be higher than the anticipated ones. Without complete and accurate HCC capture, ACOs may not be able to stay below the MSSP benchmark even when cost reduction efforts have been maximized. Another consideration is that joining or forming an ACO may require significant costs.
Can Medicare beneficiaries choose any provider?
Medicare beneficiaries can continue to choose any provider who accepts Medicare—even if that provider is not part of the ACO. However, beneficiaries benefit from seeing providers in the ACO network because these providers all have a vested interest in providing coordinated, high-quality care.
Does MSSP require an ACO?
Another consideration is that joining or forming an ACO may require significant costs. MSSP ACOs that include separately recognized legal entities must establish a new legal entity for the combined participants. Each ACO must also create a governing body that represents providers, suppliers, and beneficiaries.
When will the ACOs be able to use the Shared Savings Program?
April 30, 2020. On April 30, 2020, CMS made changes to the Shared Savings Program to give the 517 ACOs serving more than 11 million beneficiaries greater financial stability and predictability during the coronavirus disease 2019 (COVID-19) pandemic.
When will Medicare PFS be finalized?
The Medicare PFS final rule published in November 2019 includes updates to payment policies and payment rates for services furnished under the PFS on or after January 1, 2020. The rule also includes finalized policies for the Shared Savings Program and Year 4 (2020) of the QPP.
The Medicare Shared Savings Program: Shifting Healthcare Mindset from Volume to Value
In an effort to shift the mindset from volume to value, CMS created the MSSP in 2012, a payment model that financially rewards providers and health systems for delivering value, practicing evidence-based medicine, and helping patients reach optimum health.
Four Tools Critical for Success in Value-Based Care
To be successful in the new VBC landscape, health systems must utilize analytics tools for managing large amounts of data. Organizations coupling advanced data analytics capabilities with changes in physician compensation plans and care delivery models will succeed; those that fail to change and manage data well will go out of business.
Mastery of MSSP Tools and Strategy Scale to Other High-Risk Areas
Once health systems have experience and success increasing revenue with the MSSP, they can apply these same tools and expertise to higher-risk programs, such as Medicare Advantage (MA), Medicaid, and commercial plans.
Saving Millions with a Data-Driven Approach to the Medicare Shared Savings Program
One organization’s experience shows how health systems can make real gains through the MSSP. Mission Health, a health system in North Carolina, knew it could increase profits through the MSSP by taking a more data-informed approach.
A Data-Driven Health System Self-Evaluation Is Key to Moving Forward in VBC
Mission Health’s MSSP success started with a roadmap that led to a clear goal—increase profits through the MSSP by improving VBC. All healthcare organizations must have a clear understanding of where they are today in the journey from FFS to VBC and where they want to be in 5, 10, and 15 years.
The Opportunity for Healthcare Organizations to Thrive in VBC Landscape
Which organizations will survive the payment model shift? Data analytics is a foundational asset for any health system going forward. It is the direction that supports the roadmap to success in the new value-based paradigm.
When will CMS change the Shared Savings Program?
CMS is proposing changes to the Shared Savings Program quality performance standard and quality reporting requirements for performance years beginning on January 1, 2021, to align with Meaningful Measures, reduce reporting burden and focus on patient outcomes.
What is the proposed rule for the Shared Savings Program?
CMS issued a proposed rule that would provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are account able for repaying shared losses). These proposed policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. The proposed rule also would provide new tools to support coordination of care across settings and strengthen beneficiary engagement; ensure rigorous benchmarking; promote interoperable electronic health record technology among ACO providers/suppliers; and improve information sharing on opioid use to combat opioid addiction.
When will Medicare change to PFS?
December 1, 2020. Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. On December 1, 2020, CMS issued the Medicare PFS final rule that includes regulatory changes to the Shared Savings Program. A summary of those changes are as follows:
What is the Physician Fee Schedule?
The Physician Fee Schedule (PFS) final rule published in November 2018 addresses a subset of changes to the Shared Savings Program for ACOs proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success” and addresses various other revisions designed to update program policies under the Shared Savings Program. In order to ensure continuity of participation, finalize time-sensitive program policy changes for currently participating ACOs, and streamline the ACO core quality measure set to reduce burden and encourage better outcomes, CMS is finalizing the following policies:
What is a split/shared visit?
The definition of split/shared visits can be found in the CMS Internet Only Manual (IOM): Medicare Claims Processing Manual Publication 100-04, chapter 12, section 30.6.1.H Split/Shared E/M Visit:#N#“A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”
What is the code for a split visit?
Incident-to requirements must be met. Remember: Split/shared visits do not apply to consultations (99241-99255), critical care services (99291-99292) or procedures.
What is the role of a scribe in a hospital?
A scribe’s role is to document in the medical record a physician’s visit with the patient. In a hospital setting, a scribe makes rounds with the physician and documents the visit. Scribing is not a billable service and is not always straightforward.
Does Medicaid pay for NPPs?
Check your local state Medicaid Web site for your state’s rules. Medicaid pays NPPs on a separate fee schedule and has a separate limitation and coverage book for NPPs.#N#In Florida, NPP services under the direct supervision of a physician may be billed using the physician’s provider number instead of the NPPs provider number with some exceptions. Florida Medicaid direct supervision means the physician is on the premises when the services are rendered and he/she reviews, signs, and dates the medical record.
Shared Savings Program and Providers
Care Coordination
- Health care providers have reported that a lack of information is a barrier to improving care coordination. While a provider may know about the services they provide to the beneficiary, they often do not know about all the services the beneficiary receives from other health care providers. To better treat patients and to coordinate their care, Shared Savings Program ACOs may reques…
Telehealth
- With the passage of the Bipartisan Budget Act of 2018, new flexibilities were granted for physicians and practitioners in certain ACOs in the delivery of services through telehealth for dates of service on or after January 1, 2020. Providers and suppliers in ACOs that are in a two-sided risk track and that choose prospective assignment may bill for certain services without th…
Provider Participation
- To participate in the Shared Savings Program, Medicare-enrolled providers and suppliers must form or join an ACO, and the ACO must apply and be accepted to the Shared Savings Program. Providers and suppliers may contact other ACO participants in the region, state, or national professional associations to investigate opportunities to join an ACO. AC...
Program Intersection
- There are several Medicare initiatives that aim to promote quality improvement while lowering the growth in health care expenditures. Although these programs are separate and distinct, they interact in key areas. The following programs intersect with the Shared Savings Program.
Find Out More
- Providers and suppliers that participate in a Shared Savings Program ACO should contact their ACO for more specific information on participation in the program. For general information on provider participation in the Shared Savings Program, refer to: 1. Medicare FFS FAQs Back to Top
Medicare Shared Savings Program
Coming Together to Effect Change
- In the MSSP, teamwork is paramount. To participate, providers must be part of an Accountable Care Organization (ACO), a patient-centered network that shares financial and medical responsibilities with the goal of improving patient care while limiting unnecessary spending. The MSSP requires ACOs to promote evidence-based medicine, engage beneficiaries, report internall…
Financial Risk and The MSSP
- To understand truly understand the role of ACOs in the MSSP, one must understand the concept of financial risk. It’s the idea that ACOs in the MSSP can—and should—take on some degree of responsibility for lowering costs (i.e., ensuring that actual expenditures don’t exceed updated historical benchmark data). When they don’t accomplish this goal, they may be penalized. Howe…
Quality and The MSSP
- To be eligible for any shared savings that are generated, ACOs must also meet the established quality performance standards for 31 quality measures(29 individual measures and one composite that includes two individual component measures). These MSSP quality measures span the following four quality domains: 1. Patient/caregiver experience 2. Care coordination/pa…
The MSSP from The Beneficiary’S Perspective
- Medicare beneficiaries can continue to choose any provider who accepts Medicare—even if that provider is not part of the ACO. However, beneficiaries benefit from seeing providers in the ACO network because these providers all have a vested interest in providing coordinated, high-quality care.
Important Considerations in The MSSP
- There are several other important concepts to consider when joining an ACO as part of the MSSP. The article, What is an Accountable Care Organization (ACO), provides great insights into some overlying concerns with ACOs today. “Since the inception of ACOs in 2012, many are reaching the limit of their no-risk contracts and are considering whether they want to continue with the Medic…