Medicare Shared Savings Program ACO Compliance Education 2014

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Q: Why do I have to complete ACO compliance education? I already receive compliance training from Providence/Swedish. A: Your organization has chosen to participate in the Medicare Shared Savings Program (MSSP), which means that you are now participating in the MSSP too. There are a few things you need to know to ensure compliance with the Center for Medicare and Medicaid Services (CMS) requirements for MSSP Accountable Care Organizations (ACOs). This education module will highlight them for you.

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Q: What is a Medicare Shared Savings Program Accountable Care Organization? A: MSSP ACOs are groups of doctors and other health care providers who voluntarily work together to coordinate care for Medicare fee-for-service beneficiaries. MSSP ACOs share in any savings that result from providing beneficiaries with coordinated, high quality care. MSSP ACOs are not managed care organizations, do not use closed networks of providers, and do not limit a Medicare beneficiary's so-called “free choice” of Medicare providers.

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Q: Does an MSSP ACO differ from other ACOs? A: Yes. MSSP ACOs must meet specific regulatory requriements that other ACOs (like the Providence-Swedish Health Alliance, or so-called “Boeing ACO”) don’t. MSSP ACOs also differ because they do not have closed provider networks and primarily coordinate care for the traditional Medicare population.

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Q: What am I going to learn and does it really matter? A: This compliance education module will go through: – MSSP ACO regulatory requirements – Reporting compliance, fraud, waste and abuse issues – Who to contact with questions or concerns

And yes, compliance matters. Non-compliance could result in: – Termination of our ACO’s contract with CMS, – Repayment of substantial amounts of funding, and possibly, – Civil and/or criminal penalties for serious violations.

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Q: What am I going to learn and does it really matter? (continued) In fact, compliance matters so much that Health Connect Partners has its own compliance program, structured around the elements recommended by the Dept. of Health and Human Services Office of the Inspector General. The elements are outlined in the HCP Compliance Program Description and include: ACO Standards of Conduct

Compliance committees

Written policies and procedures

Disciplinary standards

Dedicated compliance officers

Auditing and monitoring of risks

Training and education

Lines of communication to report compliance concerns (discussed more below)

Responses to, and prevention of, potential compliance problems

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Q: If we are responsible for coordinating a patient’s care across the continuum, then can we limit referrals to only other ACO providers? A: In general, no. The MSSP is not a managed care or closed network program. This means that Medicare fee-for-service patients must be able to seek care from providers that are outside of the ACO. However, employed or contracted physicians may limit referrals in certain circumstances that are discussed next.

Please see the MSSP ACO Prohibited Referrals Policy and Procedure (ACO-02-HCP)

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Q: If we are responsible for coordinating a patient’s care across the continuum, then can we limit referrals to only other ACO providers? (continued) Employed or contracted providers may limit referrals when acting within the scope of their contract, as long as: – The referring provider is free to make a referral based on the patient’s preference; or – The patient’s insurer determines the provider; or – A referral within the ACO would not be in the patient’s best medical interests.

Example: A hospital may require its employees to refer patients to the hospital’s imaging center as long as the referring employee is free to honor patient choice, insurer requirements, and the best interests of the patient. 8

Q: Since the MSSP ACO is responsible for coordinating a patient’s care across the continuum, can we try to encourage beneficiaries to seek care from the MSSP ACO by providing free or discounted services? A: Sometimes, and only under certain circumstances. The federal government has put limitations on the strategies MSSP ACOs can use to encourage patients to seek care from the MSSP ACO. We’ll start with what MSSP ACOs may not do, then we’ll go over what MSSP ACOs may do.

Please see the MSSP ACO Beneficiary Inducements Policy and Procedure (ACO-01-HCP)

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Q: Since the MSSP ACO is responsible for coordinating a patient’s care across the continuum, can we try to encourage beneficiaries to seek care from the MSSP ACO by providing free or discounted services? (continued) MSSP ACOs may not give beneficiaries cash or items unrelated to health care under any circumstances. Examples of prohibited items include sporting event tickets or gift certificates for non-health care related retail items.

MSSP ACOs may not give beneficiaries items or services for the purposes of: – Rewarding them for receiving services from the MSSP ACO, or – Persuading them to remain assigned to the MSSP ACO.

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Q: Since the MSSP ACO is responsible for coordinating a patient’s care across the continuum, can we try to encourage beneficiaries to seek care from the MSSP ACO by providing free or discounted services? (continued) MSSP ACOs may give beneficiaries free or below market value items or services for the purposes of care coordination or encouraging health awareness. However, these items or services must be:    

“In-kind” (i.e. goods, commodities, and services, but not cash); Reasonably connected to medical care; and either Preventive care items or services, or Intended to advance one or more of the following clinical goals: – – –

Adherence to a treatment (including a drug treatment) regime; Adherence to a follow-up care plan; and/or Management of a chronic disease or condition. 11

Q: Since the MSSP ACO is responsible for coordinating a patient’s care across the continuum, can we try to encourage beneficiaries to seek care from the MSSP ACO by providing free or discounted services? (continued) Example: An MSSP ACO may give blood pressure monitors to patients with hypertension to encourage regular blood pressure monitoring and to educate and engage beneficiaries to be more proactive in their disease management. Example: An MSSP ACO may not waive or reduce Medicare copayments or deductibles because those are financial incentives and are not “in-kind.”

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Q: Since the MSSP ACO is responsible for coordinating a patient’s care across the continuum, can we try to encourage beneficiaries to seek care from the MSSP ACO by providing free or discounted services? (continued) Beneficiaries must be able to keep any items received after the MSSP ACO’s contract with CMS ends. Beneficiaries must also be able to continue receiving services that are in progress when the MSSP ACO’s contract ends. Examples: – A post-surgical patient receiving free home visits to coordinate in-home care during the recovery period; – A hypertensive patient using home telehealth monitoring of blood pressure; – A beneficiary receiving services halfway through a normal course of smoking cessation treatment.

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Q: Are there limitations on advertising or promoting our MSSP ACO and it’s benefits to patients? A: Yes- CMS has put fairly stringent limitations on what are broadly referred to as “marketing materials.” “Marketing materials” include brochures, websites, advertisements, outreach events, letters to beneficiaries, social media, etc. Examples of things that are NOT “marketing materials” include anything that does not contain information about the MSSP ACO, billing/claims documents, materials related to health conditions, provider referrals, etc.

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Q: Are there limitations on advertising or promoting our MSSP ACO and it’s benefits to patients? (continued) In general:  Marketing materials must be submitted to CMS for pre-approval;  MSSP ACOs must use CMS templates for materials when they are available; and  CMS templates can not be altered in any way. There are too many restrictions on “marketing materials” to be adequately covered here, so please contact the ACO Regulatory Compliance Department before creating, modifying, or distributing any ACO marketing materials.

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Q: Are there limitations on advertising or promoting our MSSP ACO and it’s benefits to patients? (continued) There are also some prohibited terms and phrases that may not be used in any communications about the MSSP ACO: Prohibited Phrase/Term

CMS’ Suggested Alternative

“Managed care” or “care management”

“Coordinated care” or “care coordination”

Beneficiaries “enroll” or “enrollment”

Providers “participate”

“You have been selected to participate”

“Your provider has chosen to participate”

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Q: Do we need to tell our patients about the MSSP ACO? A: Yes, CMS has some beneficiary notification requirements: – Beneficiaries must receive notice that their health care provider is participating in an MSSP ACO; – Beneficiaries must be given the option to opt-out of some data sharing between CMS and the MSSP ACO; and – Beneficiaries must be given the option to change their data sharing preferences at any time.

Since beneficiary notifications are “marketing materials,” Health Connect Partners policies and procedures regarding beneficiary notification must be followed. Please see the MSSP ACO Beneficiary Data Sharing Notification Policy and Procedure (ACO-05-HCP).

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Q: Do we need to retain records regarding the MSSP ACO? A: Yes. CMS requires that MSSP ACOs retain all records related to the ACO for a minimum of 10 years after the MSSP ACO agreement period has ended. Beyond the minimum 10-year requirement, you should follow your ministry/facility’s record retention policies and procedures. Please see the Providence Records Retention & Disposal Policy and Procedure (PROV-ICP-715).

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Q: How do I report suspected non-compliance or fraud, waste, or abuse? Also, where do I find more information on the MSSP ACO requirements? A: You have several choices: 1. ACO Regulatory Compliance Program documents (including policies and procedures, Standards of Conduct, CMS regulations, etc.) 2. Contact the ACO Regulatory Compliance Department 425-525-3739 or [email protected] 3. Call the ACO Compliance Line (callers may remain anonymous) at 888-233-4101 4. Call the Providence Integrity Line 888-294-8455

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Congratulations – you have completed the 2014 MSSP ACO Compliance Education!

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