ACO Compliance – Unique and Different!

ACO Compliance different and unique

ACO Compliance include requirements specific to the nature and operations of an ACO.  It is somewhat different than a “traditional” healthcare provider, be it a Covered Entity or a Business Associate.  An Accountable Care Organization (“ACO”) participates in the Medicare Shared Savings Program (MSSP) and allows certain Medicare Providers and suppliers to join together as an Accountable Care Organization, to be accountable for the care of a population of Medicare beneficiaries. 

For ACO Compliance, the final Rule 2011 requires to have an ACO Compliance Plan. Compliance plans are not only required but can also help ACOs meet the many complicated program requirements set forth by the Center for Medicaid and Medicaid Services (CMS).

An ACO Compliance Plan includes . . .

  • A designated compliance official or individual who is not legal counsel to the ACO and reports directly to the ACO’s governing body;
  • Mechanisms for identifying and addressing compliance problems related to the ACO’s operations and performance;
  • A method for employees or contractors of the ACO, providers/suppliers, and other individuals or entities performing functions or services related to ACO activities, to anonymously report suspected problems to the compliance officer;
  • Compliance training for ACO participants and ACO providers/suppliers;
  • A requirement for the ACO to report probable violations of law to an appropriate law enforcement agency; and
  • Be in compliance with and periodically update Policies & Procedures, including HIPAA related changes in laws and regulation.

ACO Compliance Investigations . . .

The ACO Compliance Plan must be made available to the Centers of Medicare and Medicare Services (CMS) which will allow for prompt and thorough investigations of possible misconduct by (1) ACO participants, (2) ACO providers/suppliers, other (3) individuals or entities performing functions or services related to ACO activities, (4) corporate officers, (5) managers, (6) employees, and (7) independent contractors.

ACO Compliance assures early detection and ability to report violations and are minimizing the loss to the Federal government from false or improper claims. This is an area in which the ACO Compliance Officer should take a proactive approach with self-audits, regular reviews, and updates to policies and procedures to minimize these losses.

ACO Compliance and Shared Savings Benefits . . .

In 2014 for example, Memorial Hermann ACO in the state of Texas earned a shared savings payment of $28,338,705 for generating a saving of $57,834,092 for 34,430 assigned beneficiaries. However, if an ACO does not meet the requirements set forth by CMS, they’re subject to a downward adjustment.

If an ACO meets all requirements set forth by the MSSP, including the development and maintenance of a compliance program, they receive a percentage of all savings in the Medicare program expenditures during the performance year in comparison to national benchmarks.

The ACO requirements set forth by the CMS can become extremely complicated. It is imperative that an ACO Compliance Plan is in place and meaningful training programs are conducted annually to reach all participants.

When you need proven expertise and performance

Cindy Winn, MBA, CHSP

Ms. Cindy Winn has over 20 years of healthcare experience and expertise in operations, project management, and is certified as a HIPAA Security Professional (CHSP).

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