Accountable care organizations are comprised of physicians, hospitals and other health care providers who give coordinated care to Medicare patients with the dual goal of increasing quality and lowering costs. The Center for Medicare and Medicaid Innovation was created by the Affordable Care Act partly to test whether ACOs work, and the jury is still out. Controversies also swirl over whether ACOs are instigating consolidation in the health care sector. The government policymakers and industry experts in this session will assess the effectiveness of ACOs, the changes they deem necessary to improve the model and their eventual impact on Medicare and the nation’s health care.

1. © 2015 Haynes and Boone, LLP
ACCOUNTABLE CARE ORGANIZATIONS:
MEDICARE’S NEXT STEPS
KENYA S. WOODRUFF
Hospital of Tomorrow
U.S. News and World Report
October 20, 2015

2. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP
READING THE TEA LEAVES
• Rethinking fraud and abuse laws
• Capitation / risk-based payment
• Less definitive lines between payors and
providers

3. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP
Fraud and Abuse Laws
MSSP ACO Waivers
– ACO Pre-participation Waiver
– ACO Participation Waiver
– Shared Savings Distribution
– Compliance with Stark Law Waiver for
the AKS and Gainsharing CMP
– Patient Incentive Waiver

4. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP
Fraud and Abuse Laws
New MSSP ACO Waivers (eff. 1/1/2017)
– SNF 3-Day Rule
– Billing and payment for tele-health
services

5. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP
Fraud and Abuse Laws
PROPOSED STARK REVISIONS
– Clarification of writing and term
requirements
– Broadening of holdover allowances and
the fair market value exception
– New exception for certain timeshares
– Expansion of temporary noncompliance
with signature requirements exception

6. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP
CAPITATION / RISK-BASED PAYMENT
Investment Model (June 2015)
– An upfront, fixed payment
– An upfront, variable payment
– A monthly payment varying amount
depending on the size of the ACO
Nex Gen (March 2015)
– Population-Based Payments
– Capitation

7. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP
PAYOR / PROVIDER RELATIONSHIPS

8. © 2015 Haynes and Boone, LLP
© 2015 Haynes and Boone, LLP

9. © 2015 Haynes and Boone, LLP
Kenya S. Woodruff
Kenya.woodruff@haynesboone.com
214-651-5446