Q & A

Question 1:  What is ACO?
Answer:   An Accountable Care Organization (ACO) is an entity where Medicare providers (physicians, hospitals, etc.) can participate in with the goal of improving the quality of medical care rendered to the patients in a community, while at the same time reducing the overall cost of care. The ACO program launched by CMS is called Medicare Shared Savings Program (MSSP), wherein CMS is willing to share the savings generated by the reduced cost of care with the ACO. The ACO in turn passes on some of this saving to the participants.
 
Question 2:  How many MSSPs ACOs are currently functional?
Answer:  There are over 260 MSSP ACOs functional across the country. As o June 1, 2013 there are 10 MSSP ACOs approved in New Jersey.
 
Question 3:  In a group practice, how does ACO participation work?
Answer:  Medicare requires ACO participation to be by TINs. In other words, if your practice TIN is registered as a ACO participant, ALL physicians who submit claims to Medicare under that TIN become participants in the ACO. If any one physician in the TIN declines to be a participant, your group practice cannot join the ACO.
 

Question 4:  How are patients assigned to the ACO?
Answer:  The patient assignment process is done by Medicare. The claims data for the last 3 years is analyzed for a given patient, and the patient is assigned to the physician who has the most amount of primary care claims paid out by Medicare. The patient then becomes the part of the ACO in which this physician participates.
 
Question 5:  Can patients choose which ACO they want to belong to?
Answer:  No, this decision is made by CMS strictly based on past claims data. The patient however has the option to choose not to share the program completely. As part of the ACO participation, the ACO is required to send out notification to the patients about their ACO assignment. At that time the patient has the right to choose not to share.  The patient may choose to see any provider, regardless of whether the provider that the patient has chosen participates in any ACO or not.
 
Question 6: How will the physician know which patients are assigned to his/her practice?
Answer:  When the ACO application is approved, Medicare shares with the ACO a prospective list of patients that are assigned to the ACO.
 
Question 7:  How does participating in an ACO affect the billing?
Answer:  There is no change in the billing, or the way you go about running your practice. You will continue to bill Medicare for the Medicare patients you render care to, and Medicare will continue to pay you just like before.
 
Question 8:  How does Medicare calculate the savings?
Anaswer:  Once the patients are assigned to an ACO, Medicare looks at the past claims history on those patients. Using this data and applying certain factors to give more importance to the most recent years, Medicare comes up with the total annual spend that Medicare has on the patient pool. To this, Medicare applies some growth factors in line with the projected national healthcare spend growth and the risk factors associated with the patients. Medicare then gives a “Projected Benchmark” to the ACO, which in simple words is the projected spending for a calendar year that Medicare expects on the patients belonging to the ACO. At the end of the calendar year, if the overall cost the Medicare incurs on the patients in the ACO is less than the Projected Benchmark, the difference between the two becomes the “Savings” of the ACO.
 
Question 9:  How does Medicare share the savings with the ACO?
Answer:  Medicare expects a minimum of 3% savings rate to share the savings with the ACO. The actual amount of savings shared depends on three criteria: (1) The savings rate (2) The size of the ACO in terms of number of Medicare beneficiaries assigned to the ACO (3) The quality metrics of the ACO.
 
Question 10:  What are Quality MetricsAnswer:   Medicare requires the ACO to submit data pertaining to 33 quality metrics as part of this program. These quality metrics are reported using the claims, direct submission via online resources, and patient surveys. Most of these quality measures are in line with the PQRS guidelines that you might already be following.

 
Question 11:  What is the overall spending is 'more' than the projected benchmark? What am I liable for?
Answer:   In the kind of ACO program that NJ Physicians ACO is applying to, there is NO RISK, i.e. if the overall spending is 'more' than the projected benchmark, there is no penalty.
 
Question 12:   What is the advantage of joining NJ Physicians ACO?
Answer:   NJ Physicians ACO is fully owned and governed by community physicians like yourself. The emphasis is on creating savings strategy centered around a typical outpatient independent practice. This way the goals of all participants are aligned resulting in better outcomes. More importantly, the ACO will be operated like a small business like your practice, and hence be very efficient in terms of resource utilization. The end result is more net savings to be disbursed to the participating physicians.
 
Question 13: Where does NJ Physicians ACO stand right now?
Answer: NJ Physicians ACO has been approved by CMS to as an Accountable Care Organization participating in the MSSP program.  The participation in the program begins January 1, 2014.
 
Question 14: Who should I reach out to if I have any questions?
Answer:   NJ Physicians ACO is operated by independent physicians. The best person to reach out to will be the physician who referred you to us. In case you just heard about us elsewhere, please feel free to drop in an email to us at info@njphysiciansaco.com and we will call you back promptly. Thank you for your interest in NJ Physicians ACO and we look forward to you joining our team soon.
 
You may also visit www.medicare.gov/acos.html or call 1-800-633-4227 (TTY user shaould call  1-877-486-2048) for general questions or additional information about Accountable Care Organizations.