For Providers

AMERICA’S ACO INFORMATION FOR PROVIDERS

Why was AMERICA’S ACO Formed?

America’s ACO was initiated on January 1, 2020 as an MSSP ACO to proactively respond to federal initiatives by CMS aimed at coordinating patient care to reduce system waste and
achieve better patient outcomes. The formation of America’s ACO allows participating providers to embrace innovative CMS payment models that reward efficient quality care, and
in efforts to preserve financial solvency and independence in the midst of paradigmatic change and reform in the current value-based healthcare environment.

As a healthcare provider, must I participate in a Medicare Shared Savings Program ACO?

Participating in an ACO is purely voluntary for providers.

What type of Medicare Shared Saving Program ACO is AMERICA’S ACO?

America’s ACO is a level E two-sided risk Medicare Shared Savings Program ACO under the new “Pathways to Success” Program. The level E ACO status qualifies for participation in an advanced alternative payment model under the Quality Payment Program. Providers participating in an advanced alternative payment model are eligible to receive additional incentive payments from CMS and are exempt from participation in merit-based incentive payment system, or MIPS, reporting requirements and potential downward payment adjustments.

Why should I consider participating with America’s ACO)?

1. Participants have the opportunity to receive shared savings from the ACO as the network demonstrates its ability to lower health care costs while meeting CMS quality standards.

2. Full access to the robust state-of-the art Guardian Health Information Exchange (HIE) platform. The Guardian HIE architecture provides the capability for a) electronically moving clinical information among and between disparate providers and information systems, while maintaining the meaning of the information being exchanged, b) building a complete and fluid real-time view of a patient (Patient Master Chart), through longitudinal integration of patient health data/information at points of care, c) accessing the right information at the right time for clinical decision-making, and avoiding duplication of services and reducing medication and medical errors, d) optimizing compliant and audit-proof medical risk adjustment, e) monitoring and comparing performance relative to outcome parameters across the network, and f) engaging the patient through portal access to their own personal medical data, and g) fully satisfying the technology requirements of MIPS and APMs.

3. Access to a network of over 1,000 Independent Specialists that provide clinically integrated services to Medicare and commercial patients aligned with America’s ACO.

4. 4. Access to targeted evidence-based programs provided by Guardian Health Services (GHS) and driven by the Guardian HIE architecture directed at a) ensuring timely and effective
transitions of care, b) analytic modeling and stratification of high risk patients with corresponding opportunities for engagement with formal complex care management
services, c) on-going identification and closure of quality performance measure gaps, d) effective referral management to ensure timely and cost-efficient coordination of care, e)
systematic monitoring of medical risk adjustment and HCC coding and documentation, f) diversion of patients from inappropriate use of ERs, and g) a comprehensive telemedicine
program, and h) systematic monitoring patient experiences and satisfaction with care on the practice/provider level.

5. Access to innovative community-based service delivery platforms that serve as high quality and cost-efficient alternative to hospital sponsored and driven platforms. A sampling

of these platforms include a) a Radiology Benefit Manager (RBM) program dedicated to integrating independent radiology centers and services and reduce unnecessary and costly

imaging, b) a hospitalist platform dedicated to providing timely, comprehensive, cost-effective, and appropriate evidence-based inpatient medical care to network patients and

reduce leakage, c) a post-acute care platform dedicated to penetrating the hospital to SNF revolving door and significantly reducing costs, and d) a network of services/setting (e.g.,

radiation oncology, cath labs, outpatient surgery centers) dedicated to providing high quality and cost-efficient alternatives like services provided in hospital settings.

Can I participate in multiple Medicare Shared Saving Program ACOs?

Each taxpayer identification number or CMS Certification Number (CCN) billing Medicare for primary care services (as defined in the MSSP regulations at §425.20) must be exclusive to one MSSP ACO’s certified list of ACO participants. Exclusivity in America’s ACO only applies to Medicare FFS and does not preclude you or your practice from participating in other IPA or payer network arrangements.

According to CMS, the following provider types must be exclusive to a single ACO:

- Addiction medicine
- Cardiology
- Endocrinology
- Geriatric psychiatry
- Gynecology/oncology
- Hematology
- Hematology/oncology
- Medical oncology
- Multispecialty clinic or group practice
- Nephrology
- Neurology
- Neuropsychiatry
- Osteopathic manipulative medicine
- Obstetrics/gynecology
- Physical medicine and rehabilitation
- Preventive medicine
- Primary care (e.g., internal medicine, general practice, family practice, geriatric medicine, or pediatric medicine)
- Psychiatry
- Pulmonary disease
- Sports medicine

Are all providers who bill Medicare under a single TIN required to participate in an ACO

or can some decide not to participate?

Medicare requires a list of ACO participant TINs in order to attribute a given provider, practice, or hospital to an ACO. Therefore, CMS requires all providers who bill Medicare under

a single TIN to agree to participate in the ACO.

How are shared savings distributed in America’s ACO?

America’s ACO retains 30% of shared savings for administrative and operational expenses costs and reinvestment in the growth of the ACO. The remaining 70% is distributed to

America’s ACO primary care participating providers.

How are Medicare beneficiaries assigned to America’s ACO?

Beneficiaries (patients on Fee for Service or “Original” Medicare) are assigned to America’s ACO if they receive the plurality of their primary care services from PCPs (physicians or non-physician practitioners) with our ACO.

How does participation in America’s ACO impact Medicare Fee for Service payments to individual practices or practitioners?

Providers continue to submit claims to Medicare under their existing Tax ID and NPI numbers, and Medicare reimburses on a fee-for-service basis as they have in the past. For America’s ACO participants, CMS provides routine reporting for assigned beneficiaries including information on utilization, cost, and quality to the ACO to determine performance

against the established benchmark. America’s ACO disseminates the data throughout a performance year and offers feedback on various measures to assist in the effort of

enhancing performance and achieving savings.

What is the impact on Medicare Beneficiaries if a provider chooses to participate in America’s ACO?

Fee-for-service Medicare beneficiaries treated by providers who are participating in America’s ACO maintain all of their Medicare rights, including the right to choose any doctors and

providers that accept Medicare. Whether a provider chooses to participate in an ACO or not, their existing Fee-for-Service Medicare Patients’ may continue to see them.