Tuesday, August 15, 2017

Next Generation accountable care organization model (NGACO Model)

Next Generation Accountable Care Organization Model (NGACO Model)


The Centers for Medicare & Medicaid Services (CMS) has launched a new accountable care organization (ACO) model called the Next Generation ACO Model (NGACO Model). The twenty-one ACOs participating in the NGACO Model in 2016 have significant experience coordinating care for populations of patients through initiatives, including, but not limited to, the Medicare Shared Savings Program and the Pioneer ACO Model. Building on experience from the Pioneer ACO Model and the Medicare Shared Savings Program, through this new model, CMS will partner with ACOs that are experienced in coordinating care for populations of patients and whose provider groups are ready to assume higher levels of financial risk and reward. This is in accordance with the Administration’s goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to alternative payment models, such as ACOs, by the end of 2016 -- and 50 percent by the end of 2018.

Medicare ACOs have grown to over 477 nationwide, currently serving nearly 8.9 million beneficiaries since the Medicare Shared Savings Program and Pioneer ACO Model began in 2012. The results from the past 4 years have demonstrated that ACOs can provide better quality of care for beneficiaries while producing savings.

Selected Organizations

The NGACO Model organizations represent a variety of provider organizations and geographic regions, and were selected by fulfilling specific eligibility criteria outlined in the Request for Applications found at the Next Generation ACO Model web page. These organizations were selected through an open and competitive process from a large applicant pool that included many qualified organizations.

The 21 organizations participating in the NGACO Model in 2016:

NGACO Model Name Location
Accountable Care Coalition of Southeast Texas Inc. Houston, Texas
Baroma Accountable Care, LLC Miami, Florida
Beacon Health Brewer, Maine
Bellin Health DBA Physician Partners Green Bay, Wisconsin
Cornerstone Health Enablement Strategic Solutions (CHESS) High Point, North Carolina
Deaconess Care Integration Evansville, Indiana
Henry Ford Physician Accountable Care Organization Detroit, Michigan
Iowa Health Accountable Care West Des Moines, Iowa
Optum Accountable Care Organization Phoenix, Arizona
MemorialCare Regional ACO Fountain Valley, California
OSF Healthcare System Peoria, Illinois
Park Nicollet Health Services St. Louis Park, Minnesota
Pioneer Valley Accountable Care Springfield, Massachusetts
Prospect ACO CA Los Angeles, California
Regal Medical Group Northridge, California
River Health ACO Harrisburg, Pennsylvania
Steward Integrated Care Network Boston, Massachusetts
ThedaCare ACO Appleton, Wisconsin
Triad HealthCare Network Greensboro, North Carolina
Trinity Health ACO Livonia, Michigan
WakeMed Key Community Care Raleigh, North Carolina

The NGACO Model’s Core Principles

Protect Original Medicare beneficiaries’ freedom to seek the services and providers of their choice;
Engage beneficiaries in their care through benefit enhancements designed to improve the patient experience and reward seeking care from ACOs;
Create a financial model with long-term sustainability;
Utilize a prospectively-set benchmark that: (1) rewards quality; (2) rewards both improvement and attainment of efficiency; and (3) ultimately transitions away from an ACO’s recent expenditures when setting and updating the benchmark;
Mitigate fluctuations in aligned beneficiary populations and respect beneficiary preferences by supplementing a prospective claims-based alignment process with a voluntary process; and
Smooth ACO cash flow and support investment in care improvement capabilities through alternative payment mechanisms.
Medicare ACOs are comprised of groups of doctors, hospitals, and other health care providers and suppliers who come together voluntarily to provide coordinated, high-quality care at lower costs to their Original Medicare patients. ACOs are patient-centered organizations where the patient and providers are true partners in care decisions. Participating patients will see no change in their Original Medicare benefits and will keep their freedom to see any Medicare provider. Provider participation in ACOs is also voluntary. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

The goal of care coordination is to ensure that patients, especially those with chronic conditions, get the right care at the right time while avoiding medical errors and unnecessary duplication of services. Any patient who has multiple doctors has experienced the frustration of fragmented and disconnected care: lost or unavailable medical charts; duplicated medical procedures and tests; difficulty scheduling appointments; or having to share the same information repeatedly with different doctors. ACOs are designed to lift this burden from patients, while improving the partnership between patients and doctors in making health care decisions. Medicare beneficiaries will have better control over their health care, and providers will have better information about their patients’ medical history and better relationships with their patients’ other providers. For providers, ACOs hold the promise of realigning the practice of medicine with the ideals of the profession—keeping the focus on patient health and the most appropriate care.

Medicare beneficiaries whose doctors participate in an ACO will still have freedom of choice among providers and can still choose to see providers outside of the ACO. Patients choosing to receive care from providers participating in ACOs will also have access to information about how well their doctors, hospitals, or other caregivers are meeting quality standards.

Round 2 Application Process
Round 2 Letters of Intent and applications will be made available in spring 2016.

The CMS Innovation Center
The CMS Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for Medicare, Medicaid and Children’s Health Insurance Program beneficiaries.

Working in concert with the Shared Savings Program, the CMS Innovation Center is testing a number of ACO models and has sponsored learning activities that help providers form ACOs and improve their results. More information on all of these initiatives is available on the CMS Innovation Center website at https://innovation.cms.gov/.

Sunday, August 6, 2017

Revised EFT Authorization agreement beginning January 1st 2018

Providers and suppliers must use the revised CMS-588 form (Electronic Funds Transfer Authorization Agreement) beginning January 1, 2018. The revised form will be posted on the CMS Forms List (https://go.usa.gov/xX3Sa) by early summer. Medicare Administrative Contractors will accept both the current and revised versions of the CMS-588 through December 31, 2017. Visit the Medicare Provider-Supplier Enrollment webpage for more information about Medicare enrollment and the Electronic Funds Transfer (EFT) requirements.

Changes to the form include:

New indicator shows if the EFT is for an individual or a group/organization/corporation in Parts 1 and 2 (Reason for Submission and Account Holder Information)
Now optional to list the financial institution's contact person
Four digits added to the "Provider's/Supplier's/Indirect Payment Procedure Entity's Account Number with Financial Institution," making it consistent with the industry standard

ABN New form effective on or after June 21st 2017

Are you aware there is a renewed version of the Advance Beneficiary Notice of Noncoverage (ABN) Form (CMS-R-131)? The new form was effective for use on or after June 21, 2017, and has an expiration date of March 2020. If you have not already done so, please begin using the new form

Saturday, June 3, 2017

New Medicare insurance Card with new ID

Medicare New Card with new ID, part of MACARA Initiative.

Medicare will mail new Medicare cards between April 2018 and April 2019. Your new card will have a new Medicare number that’s unique to you, instead of your Social Security number. This will help to protect your identity. The new card won’t change your coverage or benefits.

You don’t need to take any action to get your new Medicare card. Medicare will never contact you for your Medicare number or other personal information. Don’t share your Medicare number or other personal information with anyone who contacts you by phone, email, or by approaching you in person.

Friday, October 7, 2016

Co insurance and Deductible waived CPT

Approved preventive health services with co insurance and Deductible waived.


Wednesday, September 14, 2016

What is MACRA ?

What is MACRA ?

MACRA stands for Medicare Access & CHIP Reauthorization Act 2015 :

Three major steps :

1) Ending sustainable growth rate for determining Medicare payment for health care provider service

2) Making new framework for rewarding health care provider for giving better care not just more care

3) Combining our existing quality reporting program's in to one new system

These proposed changes replace a patchwork system of Medicare reporting program's with a flexible system that allows you to choose two path of links quality of payments .

MIPS - Merit based Incentive Payment System.

It's a combination of PQRS, Value based payment modifier and EHR.

APM  - Alternative Payment Model

2019 - 2024 Lump sum incentive amount, increased transparency of physician focused payment model.

Starting 2026, offers some participating health care provider higher annual payment.


MACRA Requires us to remove SSN from all Medicare cards, when replace SSN on all Medicare cards we can better protect.

Private health care and financial information.

Federal health care benefit and services payment.

Saturday, March 26, 2016

CPT Modifier 1P

Description for 1P:
Medical reasons

Guidelines for 1P Modifier:
In general, PQRI quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population that receive a particular process of care or achieve a particular outcome.
  • Where a patient falls in the denominator population but specifications define circumstances in which a patient may be excluded from the measure’s denominator population, CPT Category II code modifiers 1P, 2P, and 3P are available to describe medical, patient, or system reasons, respectively, for such exclusion
  • CPT modifier 1P: the quality measure was not applied due to medical reasons
  • This modifier is only valid with some measures
  • This modifier may only be reported with the CPT Category II codes for quality measures. It does not apply to HCPCS codes for quality measures.
  • Refer to each individual quality measure for specific indications for this modifier