HEALTH CARE Compliance & engagement Solutions

Medicare Accountable Care Organizations (ACOs) are responsible for the overall quality and cost of health care provided to their traditional Medicare beneficiary (Beneficiary) populations.[1] That statement is not as simple as you might think for Medicare Shared Savings Program (Shared Savings Program) or Next Generation Model (NextGen) ACOs.  The Centers for Medicare and Medicaid Services (CMS) aligns Beneficiaries to ACOs through a claims-based methodology requiring Participants to provide the plurality of primary care services received by a Beneficiary.[2]  For Shared Savings Program ACOs, this methodology is applied retrospectively at the end of the performance year. In other words, the ACO does not know which Beneficiaries they are responsible for each year until after the year ends.  While NextGen ACOs were granted prospective alignment, the plurality of care standard can still cause significant heartburn of its own within both programs. Participants often find that loyal Beneficiaries are not aligned to the ACO.  This can happen for any number of reasons; a common example is snow-birds who receive much of their care in another state each year.  Moreover, while this claims-based alignment methodology does consider claims billed by mid-level providers and specialists, the Beneficiary must have at least one visit with a primary care provider, or one of the specialists used for alignment.  As a result, practices that regularly use mid-level providers or include large numbers of specialists often have difficulty maintaining attribution for their patient populations.

​Recently, CMS launched a new initiative called “Voluntary Alignment” for all Medicare programs, not just ACO, that encourages Beneficiaries to actively visit and select the primary care physician they believe is most responsible for coordinating their care.[3]  This Voluntary Alignment process will supersede the claims based methodology, and will be applied prospectively in both the Shared Savings Program and NextGen Model.  The benefits are obvious - stabilizing alignment rosters and allowing ACOs to focus care coordination resources on a pre-determined population. In all the excitement for this initiative, ACOs may overlook a few drawbacks or nuances that could directly impact their performance: 

  • ACOs could be responsible for Beneficiaries who don’t actually visit participating providers.
    • Shared Savings Program ACO Beneficiary Rosters for PY 2018 will reflect the selections made by Beneficiaries up until October 31, 2017.  And, alignment supersedes claims-based alignment.
    • This means if a Beneficiary selects an ACO provider on Oct 28, 2017 but changes this selection to a non-ACO provider on Dec 15th, that Beneficiary will remain on the ACO’s Beneficiary Roster for all of PY 2018 even if they choose to never visit the original physician. Essentially, ACOs may be “stuck” with Beneficiaries on their rosters who have no intention of engaging with the ACO. This could impact the ACO’s overall quality and eligibility for Shared Savings.
  • In order for Beneficiaries to be eligible for alignment to the ACO, they still must have at least one primary care service with an ACO participating primary care physician or a physician whose specialty is used in alignment.  If a practice uses mid-levels regularly or has large numbers of specialists, Voluntary Alignment may not resolve issues with alignment to the practice.
  • CMS has yet to finalize the reporting mechanisms associated with Voluntary Alignment.  Many ACOs are looking for the ability to see real-time selections.  At a minimum, ACOs hope CMS will be able to provide an indicator in claims files to show Beneficiaries aligned (or lost) as a result of Voluntary Alignment. 

Even with these hurdles, ACOs will likely benefit from the ability to stabilize the roster.  The question then becomes, how can ACOs take advantage of this new initiative?  CMS will notify Beneficiaries about Voluntary Alignment via an updated “Medicare & You” handbook. ACOs should also actively communicate with Beneficiaries, participating providers and office staff about Voluntary Alignment. It’s an excellent opportunity to further engage Beneficiaries in their health and educate them on their provider’s participation in an ACO.  As ACOs develop a communication strategy they should consider the following: 

  • DO NOT incentivize, coerce, or influence Beneficiaries to designate or not designate a particular provider.
  • Distribute the Beneficiary Handout to all Shared Savings Program ACO participants. CMS updated the handout to include language about Voluntary Alignment. The handout is required to be available upon request in all Shared Savings Program participating provider offices.  Don't forget to file the updated handout as a template material used without modification with CMS.
  • Utilize CMS materials to educate participating providers and office staff.  Since they are on the front lines, office staff should be equipped with resources to help prepare them for questions coming from Beneficiaries. These are two pieces that are particularly informative and available in the SSP Portlet.
    • Voluntary Alignment ACO Fact Sheet
    • Voluntary Alignment Beneficiary Fact Sheet
  • 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.

Voluntary Alignment is the next iteration of Beneficiary assignment for Medicare ACOs.  Is your ACO ready to take advantage of the benefits of a more predictable population of aligned Beneficiaries?

[1] “Accountable Care Organizations (ACOS): General Information.” Centers for Medicare & Medicaid Services. Last updated: September 5, 2017.
[2] “Medicare Shared Savings Program: Shared Savings Losses and Assignment Methodology Specifications.” Centers for Medicare & Medicaid Services. Last updated: April 2017.

[3] “Voluntary Alignment: For Medicare Shared Savings Program ACOs.” [PowerPoint slides]. Centers for Medicare & Medicaid Services. August 23, 2017. 

WRG_WPVA_IAApproved 09/12/17


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.​

Voluntary Alignment

THE medicare initiative changing the aco game

Kimberly Busenbark & Maddie Short, Wilems Resource Group


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