Tag Archives: Shared Savings Program

Healthcare Alert: CMS issues guidance and ACO physician exclusivity

The Centers for Medicare & Medicaid Services (CMS) recently updated its Medicare Shared Savings Program (MSSP) FAQs by adding 13 questions and answers that provide important guidance on the ability of physicians to participate in multiple accountable care organizations (ACOs).

Contrary to the common misconception that only primary care physicians are required to be exclusive to a single ACO, and that specialists are free to participate in multiple ACOs, the update clarifies that if a group practice (or other entity) bills Medicare for services under any of the billing codes that fall within the definition of “primary care services,” the taxpayer identification number (TIN) of the group is not allowed to appear on the participant lists for multiple ACOs. It is important to keep in mind that the ACO regulations broadly define “primary care services” as all services that fall within certain billing codes, including CPT codes for evaluation and management (E&M) services in various office, outpatient, nursing facility and home settings, regardless of the specialty of the physician. Primary care physicians and specialists alike will therefore generally be precluded from participating in multiple ACOs if their services are billed under any of these E&M codes, or if the services of other physicians, nurse practitioners, physician assistants or clinical nurse specialists are billed by their practice entity under those codes.

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ACO Fraud and Abuse Law Waivers

Part two in the ACO series is an analysis of the Fraud and Abuse Law Waivers (Stark Law, Anti-Kickback Statute, Civil Monetary Penalties) for those ACO’s in the Shared Savings Program.

For more information please visit www.omwhealthlaw.com or click on the headline above.

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