The Medicare Direct Contracting (MDC) program is an unique opportunity for:
- Existing Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs)
- Next Generation ACOs (NextGen ACOs)
- Medical groups participating in the CPC+ program
- Provider or payor organizations that have experience serving Medicare fee-for-service (FFS)
- Provider or payor organizations with limited Medicare FFS experience
Full Answer
What is the Medicare direct contracting model?
Apr 22, 2019 · Direct Contracting (DC) is a set of voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). The payment model options available under DC create opportunities for a broad range of organizations to participate with the Centers for Medicare & Medicaid Services …
What is direct contracting in healthcare?
Feb 25, 2022 · Medicare Direct Contracting is essentially a new way for the Centers for Medicare and Medicare Services (CMS) to pay for covered health care costs. Direct Contracting Entities, or DCEs, are currently available in all but a few states. Depending on where you live, you may already be enrolled in one or have the option to do so.
Where can I find more information on Medicare direct contracting?
Direct Contracting: Quietly Handing Medicare to Wall Street. What is the Medicare Direct Contracting (DC) Program? DC is a pilot program that aims to enroll every Traditional Medicare beneficiary into a third-party “Direct Contracting Entity” (DCE). Instead of paying doctors and hospitals directly for care, Medicare gives DCEs a monthly payment to cover a defined portion …
When does Medicare direct contracting (MDC) start?
The Medicare Direct Contracting (MDC) program is an unique opportunity for: Existing Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) Next Generation ACOs (NextGen ACOs) Medical groups participating in the CPC+ program Provider or payor organizations that have experience serving Medicare fee-for-service (FFS)
What is direct contracting with Medicare?
What is Direct Contracting? Direct Contracting is a voluntary, five-year (plus an optional implementation year) alternative payment model (APM) which leverages components from the Next Generation ACO Model (NGACO), Medicare Advantage (MA), and the private sector and will be the focus of today's write-up.Mar 3, 2022
How is direct contracting different from Medicare Advantage?
Unlike Medicare Advantage, Direct Contracting empowers providers to take on the risk of providing high quality, efficient care to Medicare beneficiaries, obviating the need for a health plan to sit in the middle of Medicare, providers and patients.
What does direct contract mean?
Direct Contracting (DC) is a set of voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS).Apr 22, 2019
What is a DCE in healthcare?
A Direct Contracting Entity model framework is the performing entity comprised of strategic healthcare providers and suppliers, referred to as “Participating” and “Preferred” Providers, that operate in the program under a common legal structure.
How many direct contracting entities are there?
99 direct-contracting entitiesWithin the announcement, CMS acknowledged that there are currently 99 direct-contracting entities (DCEs).Feb 24, 2022
Is direct contracting an APM?
9. Q: Is Direct Contracting an Advanced Alternative Payment Model (APM)? Direct Contracting will be an Advanced APM starting in performance year (PY) 1 (April 1 – December 31, 2021).Nov 25, 2019
What is direct contracting for works?
Direct contracting means procurement without competition and hence proper transparency needs to be maintained. While procuring services/ good under direct contracting the institutes are expected to be cautious as it involves accountability on the part of purchaser.
What is the difference between contract and direct hire?
The primary difference between contract-to-hire vs direct hire employment lies in payroll structure. Whereas direct hire recruiting immediately makes the new hire an employee of the end-user company, a contract hire will be on the staffing agency's payroll for the duration of their contract.Aug 10, 2020
What is Clover health direct contracting?
As a CMS Direct Contracting Entity, Clover Health DCE will partner with Primary Care Physicians (PCPs) to enhance quality of care for Medicare FFS beneficiaries, support a focus on beneficiaries with complex chronic conditions and provide an alignment of incremental reimbursement.Jan 3, 2022
What is Medicare attribution?
The process that commercial and government payers use to assign patients to the physicians who are held accountable for their care is called attribution.
What is the difference between ACO and DCE?
ACOs are rewarded or penalized based on the service and performance they provide. They are paid or penalized depending on the total cost for a given payment year while DCEs come to terms with the Centers for Medicare & Medicaid Services (CMS) for an agreed-upon monthly payment.
What is Medicare Direct Contracting?
To understand direct contracting, it helps to understand the two main Medicare payment models. When you enroll in Medicare, you have two options: Original Medicare (Part A and Part B) or Medicare Advantage (Part C). Each represents a different way CMS pays providers for your care.
Are there any advantages to Medicare Direct Contracting?
There are actually a lot of potential benefits to joining a Medicare DCE. The table below lists a few of the most notable.
Will my costs go up if I join a Medicare Direct Contracting Entity?
No, your costs cannot go up if you choose direct contracting. In fact, DCEs have the flexibility to lower cost-sharing and copayments for certain services if they choose to. For example, a DCE can waive the deductible requirement for some services or charge a flat copayment instead of the usual 20% cost-sharing.
Can I use my Medicare Supplement Plan if I join a DCE?
Yes, your Medigap plan must continue to pay any out-of-pocket costs it would cover if you stayed with a fee-for-service provider. This is another major difference between Medicare Advantage and Medicare DCEs.
Do I have to buy a Part D prescription drug plan with a Medicare DCE?
Yes, you still have to enroll in Part D to get your prescription drug coverage and avoid any penalties. Part D is completely separate from your primary care DCE.
Can I see any doctor or only the doctors in my DCE?
You can continue to see any provider that accepts Medicare even if you are ‘aligned’ with a DCE. However, the enhanced benefits and incentives are only available through the primary care provider you selected in your DCE.
Do I lose my Medicare rights if I join a DCE?
No, you still have all your rights to appeal any charges or decisions or file a complaint against your doctor. Because you’re still covered by Original Medicare, the process for filing a complaint or appeal is exactly the same. You don’t need to negotiate with an insurance company before escalating to Medicare.
What is Medicare Direct Contracting?
Medicare Direct Contracting is essentially an advanced VBP contract for Medicare Fee-for-Service (FFS) attributed beneficiaries. It affords the opportunity to bring another population into alignment with other payer value-based payment arrangements, including for some organizations your self-insured population through your employee health plan. Having misaligned payment models across populations spells trouble for designing, building and governing networks and care models that are population agnostic. Success requires a concrete strategy for bringing all value-based payment arrangements, contracted providers and attributed members into alignment and monitoring ongoing performance while maintaining alignment.
When will the IP start?
The IP began on October 1, 2020, and will run through March 31, 2021. The first Performance Year (PY) begins on April 1, 2021, truncated by a quarter due to Covid-19 delays. Each subsequent period will follow the calendar year, through December 31, 2026. In addition to the 51 DCEs selected for the IP, DCEs selected to begin at the start ...
What is operationalization process?
Operationalization of all these elements is a multistage process. Each effort must be prioritized and sequenced to ensure feasibility, financial solvency and regulatory compliance. For leadership to have what they need to stay organized and on track, manage network and stakeholder communications on changes and challenges, and have streamlined and effective governance, they need a well-planned roadmap.
How many DCEs are there in 2021?
The Center for Medicare and Medicaid Innovation (CMMI) has announced the 51 Direct Contracting Entities (DCEs) selected to participate in the initial 2021 Implementation Period (IP) for the Direct Contracting Model Global and Professional Options. The IP began on October 1, 2020, and will run through March 31, 2021. The first Performance Year (PY) begins on April 1, 2021, truncated by a quarter due to Covid-19 delays. Each subsequent period will follow the calendar year, through December 31, 2026. In addition to the 51 DCEs selected for the IP, DCEs selected to begin at the start of the April 2021 Performance Year will be announced closer to the start of that period. CMS also recently announced that letters of intent (LOI) are due for potential applicants for MDC Geographic in 15 communities across the country (that program will be covered in a future article).
What is direct contracting?
Direct Contracting is designed to appeal to organizations that are either new, and therefore have very few existing primary care relationships with traditional Medicare beneficiaries, and/or organizations that highly value primary care capitation.
Does Medicare revenue flow through the DCE?
An important distinction is that a portion or even all of a practice’s Medicare revenue would flow directly through the DCE. In contrast, in MSSP, a practice continues to bill fee-for-service directly to Medicare while savings flow through the ACO.
Background
Earlier this year, the Center for Medicare and Medicaid (CMS) announced five new payment models designed to transform primary care by paying providers for outcomes rather than services.
What is Direct Contracting?
Direct Contracting is a voluntary, five-year (plus an optional implementation year) alternative payment model (APM) which leverages components from the Next Generation ACO Model (NGACO), Medicare Advantage (MA), and the private sector and will be the focus of today’s write-up.
Why DC?
CMS believes that DCEs having control of funds with their downstream providers will enable them to improve care coordination and delivery and to better manage the health needs of their aligned beneficiary population, resulting in reduced costs and better outcomes. As such, the proposed payment mechanism will be paid out monthly directly to the DCE.
What are we hearing from members?
After speaking with our members, it’s clear several are interested in better understanding the payment model and whether it’s the right decision for them. Although not all of our members are planning to participate in Direct Contracting, a large number are.
Key Decision Points
There are a number of key decision points that will need to be made prior to the implementation and/or performance period. Several of the key decisions are listed below. The CareJourney Direct Contracting Analysis will provide the key analytics needed to make an informed decision.
Common Approaches to the Implementation Period
The implementation period is intended to help New Entrants DCEs build an aligned FFS population by testing enhanced opportunities for voluntary alignment. This period provides DCEs with additional time to engage in alignment activities and plan their care coordination with management strategies prior to the first performance year. 6
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