Additional Public Disclosures
Medicare Shared Savings Program Waivers of the Fraud and Abuse Laws – Required Public Disclosures
As of July 1, 2019, the Physicians Alliance, LLC (“ACO”) entered into a five (5) year and six (6) month Participation Agreement in the Medicare Shared Savings Program (“MSSP”) with the Centers for Medicare and Medicaid Services (“CMS”).
DISCLOSED ARRANGEMENTS PROTECTED UNDER ACO PARTICIPATION WAIVER
ACO’s governing body has duly authorized the below arrangements that qualify for the ACO Fraud and Abuse Waivers, and specifically the ACO Participation Waiver, through Resolutions adopted by unanimous written consent. The ACO Managing Board has made a bona fide determination that each arrangement is reasonably related to the purposes of the MSSP because it promotes accountability for the quality, cost, and overall care for a Medicare population as described in the MSSP, provides for the management and coordination of care for Medicare fee-for-service beneficiaries through the ACO, and/or encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery for patients, including Medicare beneficiaries. Thus, the ACO, pursuant to its governing body’s authorization, is asserting the ACO Participation Waiver’s protection over all of the ACO arrangements entered into as of the beginning of the current MSSP Participation Agreement term (July 1, 2019).
To comply with the ACO Participation Waiver’s requirements, the ACO is publicly disclosing the below arrangements. ACO will publicly disclose additional arrangements that qualify for the ACO Participation Waiver as they are authorized by its governing board on this website, in compliance with CMS’s public disclosure requirements.
Supplier Value-Based Payment Arrangements:
The ACO implements various value-based care incentive payment methodologies with respect to participants in the ACO (“ACO Participants”), attendant to certain value-based care programs, some of which are supported by software (the “Supplier Value-Based Payment Arrangements”). Under the Supplier Value-Based Payments Arrangements, ACO may provide ACO Participants with augmented payments for certain qualifying Medicare evaluation and management (“E&M”) services furnished to Medicare beneficiaries assigned to the ACO and billed through the ACO Participant’s TIN (not including copayments and deductibles paid by patient or Medicare supplemental plans). The amount of these augmented payments is dependent upon the achievement of certain performance metrics and value-based goals by ACO Providers/Suppliers as part of their care coordination with the ACO, including increased adherence to ACO quality assurance and improvement programs and evidenced-based medicine guidelines aimed at improving quality and efficiency of care, and compliance with specific timeliness, claims submission, and documentation requirements associated with those E&M services.
Under the Supplier Value-Based Payments Arrangements, including but not limited to in coordination with the Networks (as listed below), ACO may provide ACO Participants with certain incentive payments in exchange for participating in care coordination with certain clinical entities affiliated with the ACO and its parent companies and enrolling such ACO Participants’ high-risk/high-needs beneficiaries in supplemental clinical care programs whereby clinicians employed by the clinical entities provide supplemental clinical services, including chronic care management, certain homecare services, remote patient monitoring services (including the provision of monitoring hardware and software), and behavioral health integration services to such beneficiaries.
Additionally, under the Supplier Value-Based Payments Arrangements, the ACO has implemented a program of incentive-based payments whereby ACO Participants receive an advance on shared savings payments on a monthly basis during each respective participation year, and where such payments are conditional upon such ACO Participant’s performance against quality and engagement metrics established by the ACO in support of the goals of the MSSP, and ACO may provide ACO Participants with enhanced payments where such ACO Participants agree to share a minimum amount of such payments as specified by the ACO from time to time with non-physician staff of the ACO Participant.
ACO has also implemented a program providing for the availability to ACO Participants and Networks an application of Stellar Health Group, Inc. to track achievement of certain goals related to the MSSP, and ACO Participants shall earn credits relevant to certain payment methodologies in the form of Stellar Value Units ™.
Infrastructure Payments Arrangement:
Under the Infrastructure Payments Arrangements, in order to fund ACO Participants’ infrastructure redesign of their primary care patient workflows, ACO may provide three months of supplemental payments above the Medicare Physician Fee Schedule amounts for certain pre-determined Medicare evaluation and management services.
Electronic Medical Records Services and Support:
In coordination with Vytalize Health, LLC. (“Vytalize”), a management services organization, the ACO has entered into arrangements whereby it will subsidize the acquisition and maintenance costs associated with electronic medical records software and technical support services to further all of its ACO Participants’ efforts to effectively use information technology platforms for ongoing population health, quality improvement, and care coordination activities, which are primarily intended for the benefit of Medicare beneficiaries.
Telehealth & Technology Services Support:
In coordination with Vytalize a management services organization, the ACO has entered into arrangements whereby it will subsidize certain telehealth, software, and communications technology-based services, including but not limited to electronic medical record systems, care coordination software, clinical consulting platforms, quality reporting tools, and remote patient monitoring (collectively, the “Technology Services”).These Technology Services are intended to further ACO’s efforts to effectively use information technology platforms for telehealth services, ongoing population health, quality improvement, and care coordination activities for the benefit of Medicare beneficiaries being treated by ACO Participants and ACO providers/suppliers, as those terms are defined within 42 C.F.R. Part 425.
Primary Care Physician and Staff Education:
In coordination with Vytalize, the ACO has entered into arrangements whereby it will compensate primary care physicians and staff for attending meetings that support the treatment and coordination of care of Medicare beneficiaries treated by the ACO Participants and ACO providers/suppliers, as those terms are defined within 42 C.F.R. Part 425. Staff will be compensated for proper coding review and related training. These meetings and training activities allow the ACO to further advance its care coordination and quality improvement efforts.
Non-Physician Licensed Clinical Provider Staffing:
In order to enhance care coordination and manage the wellness of Medicare beneficiaries, the ACO, in coordination with Vytalize and certain of the Networks, has entered into arrangements whereby it will provide non-physician licensed clinical providers to physician group practices. These services are intended to further support the treatment and coordination of care of Medicare beneficiaries attributed to ACO Participants and ACO providers/suppliers, as those terms are defined within 42 C.F.R. Part 425.
Network Relationships:
The ACO has entered into agreements by and between ACO, Vytalize, the sole member of the ACO, and certain Networks set forth below to build collaborative partnerships with Networks of independent clinicians and medical practices who will perform certain administrative services in furtherance of the goals of the MSSP which are typically performed by the ACO, for the benefit of ACO Participants participating in the Network, including but not limited to facilitation of the payments under the Supplier Value-Based Care Arrangements.. The Networks also engage Vytalize to provide certain telehealth and communications technology-based services and arrange for the provision of services for the benefit of ACO Participants aligned with the Network.
The Networks with which the ACO has entered into such agreements presently include the following:
