HEALTH CARE Compliance & engagement Solutions

Engagement and incentives and inducements, oh my!

Motivating beneficiaries in an aco world

Maddie Short & Kimberly Busenbark, Wilems Resource Group


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Doctors, hospitals, and other health care providers recognize the need for high quality, coordinated care for their patient populations. That’s why many have voluntarily chosen to participate in an Accountable Care Organization (ACO). A major pillar of Medicare ACOs is getting Medicare beneficiaries the “right care at the right time” to reduce unnecessary medical expenses.[1]  The participating providers are committed to truly improving the patient experience while helping to reign in unnecessary health care spending, but are beneficiaries willing to play ball?  Before ACOs can even deliver the right care at the right time, beneficiaries must make the “right choice at the right time”.  Individuals make active decisions that greatly impact their overall health care experience, their relationship with their physician, and the outcomes of the ACO. So, how do ACOs encourage beneficiaries to take an active role in their health care and make quality choices?

Engagement. Incentives. Inducements. ​

All beneficiaries, not just the chronically ill, should be actively engaged with their ACO provider and care coordination team. ACOs, on behalf of the provider, should regularly communicate with beneficiaries about available resources (e.g. care coordination) and initiatives (e.g. free Medicare Annual Wellness Visit).  ACOs can leverage print (e.g. post cards, magazines) or electronic media (e.g. emails, patient portals) to increase awareness of health education and ACO activities.  

CMS has started to place great emphasis on beneficiary engagement. Beyond requesting that ACO applicants provide narratives detailing beneficiary engagement strategies, CMS has implemented their own initiative in the Next Generation Model, called the Coordinated Care Reward.  Under this initiative CMS will pay beneficiaries $25 for receiving a Medicare Annual Wellness Visit from a Next Generation ACO Provider.
[2] Although Medicare ACOs should not use cash or cash equivalents to engage beneficiaries, there are many other opportunities to implement incentive programs.

You can lead a patient to water, but you can’t make him drink…or perhaps you could if he enjoyed drinking from a new water bottle.  The Nominal Value Exception from the Office of Inspector General (OIG) allows items of "nominal value" to be provided to Beneficiaries.
[3] The OIG defined nominal value as any item or service worth less than $15 in any particular instance and not more than $75 in the aggregate per person, per year. This exception requires documentation of each incentive provided to an individual to ensure that the $75 aggregate limit is not exceeded.  This means that ACOs can build a program that distributes items such as water bottles, pill boxes, cooling towels, and first aid kits – as long as they do not exceed these values. If an ACO wants to distribute items or services of greater value, the Beneficiary Inducements Waiver provides an avenue to do so compliantly.

The Beneficiary Inducements Waiver waives the Beneficiary Inducements CMP and the Federal Anti-Kickback Statute for medically related incentives offered by Medicare ACOs to encourage preventive care or compliance with treatment regimes, so long as the following are met:  ​

  • The ACO has entered into a Participation Agreement under the Medicare Shared Savings Program or Next Generation ACO model and remains in good standing.
  • There is a reasonable connection between the items/services provided and the medical care of the Beneficiary, and:
    • the items/services provided are in-kind (no cash or cash equivalents)
    • the items/services are:
      • Preventive care items/services; or
      • Advance one or more of the following clinical goals:
        • Adherence to a treatment regime
        • Adherence to a drug regime
        • Adherence to a follow-up care plan
        • Management of a chronic disease or condition
        • The item/services are not offered as an incentive to receive services from, or remain in, the ACO.
  •  The item/services are not offered as an incentive to receive services from, or remain in, the ACO.

As ACOs develop a beneficiary engagement strategy that leverages in-kind items or services they should consider the following: 

  1. DO NOT utilize items to incentivize, coerce, or influence beneficiaries to receive services from, or remain in, the ACO (e.g. incentives for voluntarily aligning to an ACO provider).
  2. Create documentation to clearly explain details and intent of any new program, and get the ACO Governing Body to approve the incentive program.  This can help prevent the appearance of impropriety if there are unintended consequences of the program (e.g. appearance of cherry picking).
  3. Develop a tracking mechanism, if necessary, for in-kind items or services provided by the ACO, ACO Participants, or ACO Preferred Providers to Beneficiaries.  The tracking should include (1) the item/service, (2) the Beneficiary who received the item/service, (3) who provided the item/service, and (4) the date the item/service was furnished.
  4. Be creative in determining what types of in-kind items and services would improve the quality of life for recipients and encourage them to continue healthy behaviors that also benefit the ACO.
  5. Consider Branding at the Practice or Doctor level since beneficiaries trust their physicians and prefer to receive communication directly from their doctor’s office.
  6. File marketing materials for approval with CMS/CMMI prior to communicating to beneficiaries. Additional guidance can be found in the Next Gen ACO Model Participation Agreement Section V.E. or MSSP Final Rule 42 C.F.R. Section 425.310. Plan for the file & use requirement (10-day for Next Gen, 5-day for MSSP) when building communication and outreach timelines.

Is your ACO prepared to launch a program designed to engage Beneficiaries? Wilems Resource Group can help your ACO develop a Beneficiary Engagement Program that makes it easier for beneficiaries to make the right choices at the right time. 


[1] “Accountable Care Organizations (ACOS): General Information.” Centers for Medicare & Medicaid Services. Last updated: September 5, 2017.​

​[2] “Coordinated Care Reward.” Centers for Medicare & Medicaid Services. Release date: June 28, 2017.
[3] “Office of Inspector General Policy Statement Regarding Gifts of Nominal Value To Medicare and Medicaid Beneficiaries. ”Department of Health and Human Services. December 7, 2016.


Wilems Resource Group is a boutique consulting firm specializing in Compliance and Engagement solutions for the Medicare Shared Savings Program and Next Generation ACO Model. We measure success on our ability to help our clients understand program requirements, determine the appropriate level of acceptable compliance risk, and create programming that meets all regulatory requirements. We build customized compliance and engagement programs for ACOs, physicians, practice managers, and beneficiaries.  We are #raisingourlegacy.​