Healthcare providers have the option to participate in an accountable care organization (ACO) by signing a contract known as a Participating Provider Agreement. It is essential that providers review the details of these contracts with legal counsel as they may contain provisions that affect the provider's ability to practice medicine in the ACO context and beyond.
ACO regulations prevent a primary care physician from joining more than one ACO. However some participating provider agreements contain restrictions that would preclude a provider from joining another provider network, including a non-ACO independent practice association or physician-hospital organization. Many physicians participate in several provider networks, and those physicians will want to give special consideration to the restrictions outlined in an ACO agreement before signing.
Clinical Protocols and Quality Measures
Providers who have joined an ACO need to abide by the clinical protocols and quality measures adopted by the ACO. Before signing an agreement Providers should request copies of these policies and procedures, and review them thoroughly.
Under ACO regulations Providers are required to retain clinical documentation and payment records for 10 years; possibly longer in the event of a government audit. This is a much longer time frame than is generally prescribed under state law and Providers may need to modify their document retention policies in order to comply.
ACOs are mandated by law to adopt a corporate compliance plan. Providers participating in an ACO may be required to develop their own compliance plans in addition to abiding by the compliance plan of their ACO. Providers may need to accomplish several things in order to implement a compliance plan; this includes screening employees and affiliates for Medicare program exclusions and other similar sanctions. An ACO must also make sure that its own staff members and participating Providers successfully undergo compliance training.
Notification of Participation
Participation in an ACO requires that Providers notify patients via signage and also distribute pre-approved notices to ACO patient beneficiaries informing them of your practice participation in an ACO.
Participating provider agreements contain language that obligates the Provider to abide by certain federal laws including but not limited to:
• False Claims Act (31 U.S.C. section 3729 et seq.)
• Anti-kickback statute (42 U.S.C. section 1320a-7b(b))
• Civil Monetary Penalties law (42 U.S.C. section 1320a-7a)
• Physician Self-Referral law (aka Stark law, 42 U.S.C. 1395nn)
ACOs present a unique and valuable opportunity for healthcare providers, however it is important that Providers fully understand the implications of signing a participating provider agreement and the possible effects of joining an ACO.
Source: Medical Economics, Vol. 89, No. 20, Oct. 25, 2012