Medicare Shared Savings Program
ACO Compliance Program Policies and Procedures Manual
Introduction

 

As part of an increasing focus on accountability for quality and cost and an overall shift to value-based payment, CMS established the Medicare Shared Savings Program ("Shared Savings Program"). CMS's implementation of this program comes complete with the myriad regulations regarding the governance and structure of Accountable Care Organizations ("ACOs") and the incentive of shared savings derived from lowering costs. While these factors of the MSSP have received much attention since final regulations were published in November 2011,June 2015 and June 2016, the everyday compliance obligations have received significantly less. In fact, after successfully forming an ACO and completing the MSSP application process, many leaders in ACOs are left asking "Now what?"

This manual is designed to provide template policies to help ACO leadership determine the best "next steps" for the ACO, and implement procedures to ensure compliance with program requirements. The manual is not intended to be a comprehensive solution to every ACO's compliance needs, as many means of executing an effective compliance program are specific to an individual ACO. Nor does this manual establish an attorney/client privilege or relationship between NAACOS, Dentons, Wilems Resource Group and any ACO participant, provider, or supplier. However, this manual will give an engaged compliance officer (and better yet, team) the tools necessary to establish a robust program with the tools to handle the baseline requirements of keeping an ACO compliant with federal law and regulations.

ACO COMPLIANCE

CMS requires ACOs to have a compliance plan.[1] The compliance regime surrounding ACOs consists of many interconnected parts - acceptance into the program is just the beginning. CMS expects an effective compliance program, one that prevents and detects potential compliance issues proactively rather than reactively. Ideally, a compliance team will consist of a fully engaged and informed leadership team and ACO Governing Body. Finally, evidencing a "culture of compliance" with clear expectations of ethical and proper behavior best serves an ACO. [2]

As part of the MSSP, all ACOs must "agree, and must require its ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities" to allow federal authorities to audit the ACO's activities.[3] Practically, then, documentation is the key to ACO compliance - the most compliant ACO in the United States must still be able to document its compliance if CMS disputes it.

Three major sources of ACO-specific compliance guidance exist - the MSSP statute,[4] the proposed and final rules regarding the MSSP,[5] and the MSSP and Pioneer ACO Program sub-regulatory guidance located on the CMS website.[6] Additionally, the generally applicable Anti-Kickback Statute, Stark law, fraud, waste, and abuse ("FWA"), antitrust, and privacy laws each pose unique challenges to ACOs.

 

TEXT COLOR LEGEND

 

Red is used to indicate that the ACO must add ACO specific information. This may be an indication of the appropriate individual, an amount of time, or the specific processes being used by the ACO to meet that requirement.

 

Blue is used to provide additional context or information that the ACO may find useful in completing the policy and procedure.

 

Green is used to highlight cross references with other sections or policies. These references are highlighted to assist the ACO in updating references as edits are made to the policies in the future.

 

To make your additions, highlight and remove the red text before typing in the editor. To quickly remove the formatting, highlight the red text and use the "Remove Format" button.