Pathology/Lab Coding Alert

Balance risk/reward for savings payoff.

If your lab is part of an Accountable Care Organization (ACO) under the Medicare Shared Savings Program (MSSP), you need to know some changes earmarked in the recent MSSP final rule. The update modifies policies, restructures payment models, and revises benchmarking methods for ACOs.

Context: With their clinical expertise, physician and patient networks, and strong information technology infrastructure, many labs have joined the movement toward value-based care and Medicare savings by participating in ACOs

Check Out Final Rule Specifics

CMS reduced the previous ACO three-track system to the following two tracks:

• Basic:This track effectively collapses the previous tracks 1 and 2 into a single, lower-level path. Within the Basic track, CMS offers five levels, A through E, that glide from low-risk/low reward options to incrementally higher-risk models. The final level is the only one that qualifies as an Advanced Alternative Payment Model (APM) in the Quality Payment Program (QPP).
• Enhanced:» This high-risk path is basically the old Track 3 model. It “provides ACOs the highest level of risk and potential reward (up to 75 percent shared savings and up to 75 percent of loss sharing, with the loss sharing percentage being dependent on the shared savings percentage among other factors),” explain Boston-based attorneys Andrew P. Rusczek and Sarah L. Trautz of Verrill Dana LLP in online legal analysis.

Longer agreement period: The three-year timeline was replaced with a five-year agreement period. “ACOs with agreement periods that would have ended December 31, 2018 were able to opt for a six-month extension period,” advised attorneys Alex Stoflet and Claire H. Topp of Dorsey and Whitney LLP in the Dorsey Health Law Blog. “ACOs in a three-year agreement period not expiring in 2018” are able “to voluntarily terminate existing participation agreements and enter a new agreement period starting July 1, 2019 under one of the new tracks,” Stoflet and Topp note.

Patient-first policies: The final rule now requires ACOs to alert beneficiaries of their MSSP status in writing from the get-go. Plus, ACOs can offer an “incentive payment of up to $20 to an assigned beneficiary for each qualifying primary care service,” CMS says.

Benchmarking rebuild: CMS has revised its benchmarking methodologies to take into account both regional and national Fee-for-Service trends and factors. The changes are meant to entice ACOs to take on more risk while also incentivizing them to care for more complex, high-risk patients, the final rule fact sheet indicates.

Innovation overload: The final rule adds more tech and more efficiency to the MSSP. One Bipartisan Budget Act of 2018 (BBA 2018) add-in includes the finalization of telehealth for “certain ACOs under performance-based risk tracks,” the fact sheet says. Only Basic Tracks C, D, and E and the Enhanced Track are eligible for this option starting on Jan. 1, 2020.

Resource: Read the Pathways to Success/MSSP final rule fact sheet at www.cms.gov/newsroom/fact-sheets/final-rule-creates-pathways-success-medicare-shared-savings-program.