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Fraud and Abuse
CMS and OIG have proposed waivers of the application of the Stark Law, the federal Anti-Kickback Statute, and the Gainsharing CMS with regard to distributions directly related to the ACO's participation in the program. Additional waivers may apply if the party can establish that the payment or relationship meets one of the Stark Exceptions. More ...
Antitrust
In substantive terms, the Patient Protection and Affordable Care Act (PPACA) Sec. 3022 eligibility criteria regarding structure, governance and use of clinical and administrative processes are deemed "broadly consistent with the indicia of clinical integration" so as to warrant a flexible rule of reason antitrust treatment for participating ACOs. In procedural terms, it may be optimistic to assume that the agencies' antitrust review process (which is voluntary for ACOs with Primary Service Area share between 30-50 percent and is mandatory above a 50 percent share) can reliably be concluded within the stated 90-day review period. More ...
State Insurance Laws
The proposed rule outlines two alternative "tracks" by which ACOs can receive a share of savings from the delivery of health care services to Medicare fee-for-service beneficiaries. Under both tracks, however, the ACO would also bear risk and be responsible for financial losses – so CMS plans to make the "shared savings" proposition a two way street. More ...
Administrative Costs
Participation in the Shared Savings Program through an ACO is clearly not for every provider community, as participating organizations will need to develop and operate sophisticated systems to measure and promote quality, promote clinical integration and the use of evidence-based medicine, enhance care coordination, and standardization, and create and manage a host of operational and financial systems. More ...
What's My Role?
As a hospital, you are eligible to form ACOs and participate in the Program. The role you play as a physician in the Program depends on what type of physician you are. The role other health care providers and suppliers will play in the Program is less clear, but is one where CMS invites comment. More ...
Integrated Care Initiatives Beyond ACOs
The ACO program is an important initiative from many perspectives. It would be incorrect, however, to assume that the ACO program is the culmination of the federal integrated care efforts under PPACA. Rather, it is simply the beginning. Other integrated care efforts will follow. More ...
For More Information
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