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Transcript for audio podcast:
CMS Ensured Medicare Shared Savings Program Beneficiaries Were Properly Assigned

From the Office of Inspector General of Department of Health and Human Services

https://oig.hhs.gov

I'm Sheila Davis, a public affairs specialist, talking with Andrew Robinson Jr. via Skype, from our Office of Audit Services, about an audit titled CMS Ensured That Medicare Shared Savings Program Beneficiaries Were Properly Assigned: Beneficiaries Were Assigned to Only One Accountable Care Organization and Were Not Assigned to Other Shared Savings Programs. Andrew, let's start by talking about why you performed a review on the Medicare Shared Savings Program, otherwise known as the MSSP?

Sure, we reviewed the MSSP as part of OIG's body of work covering the Centers for Medicare & Medicaid Services' or CMS's administration and testing of payment and service delivery models.

The Affordable Care Act established the MSSP to facilitate the coordination and cooperation among providers and suppliers and improve quality of care for Medicare fee-for-service beneficiaries and reduce health care costs.

Eligible providers and suppliers may voluntarily participate in the MSSP by creating or joining an accountable care organization or ACO.

What is a Medicare accountable care organization, otherwise known as an ACO, and how does an ACO tie into the Medicare Shared Savings Program?

Well, a Medicare ACO is a type of health care entity formed by one or more ACO participants, such as doctors, hospitals, and other health care providers. The ACO participants are encouraged to coordinate care for their beneficiaries and reduce health care costs while improving quality of care.

In the MSSP, Medicare continues to pay ACO participants under fee-for-service. The ACO may also be eligible to receive additional payments, called shared savings payments, if they reduce health care costs and meet certain quality performance standards for their assigned beneficiaries.

You looked into something called Beneficiary Assignment…what is that?

I'm glad you asked. Beneficiary assignment is an operational process performed by CMS. It's the basis for many key MSSP operations such as determining an ACO's shared savings or losses after each performance year. Generally, a performance year is a 12 month period beginning on January first of each year.

Each performance year, CMS assigns a Medicare beneficiary to an ACO [based] on where he or she receives a plurality of primary care services as determined by the highest amount allowed by Medicare for services when compared with other ACOs, individual providers, or provider organizations. An assigned beneficiary continues to be free to choose health care providers and isn't limited to obtaining services from ACO participants.

Then, how do ACOs know their assigned beneficiaries?

For each of the performance years 2013 through 2015, CMS created two types of lists from the beneficiary assignment process and provided them to ACOs:

First, there were preliminary prospective beneficiary assignment lists. These were initial and quarterly lists of potentially assigned beneficiaries an ACO was likely to be accountable for. An ACO could use these lists to improve quality of care and reduce health care costs for those beneficiaries during the performance year.

Another type of list is the final retrospective beneficiary assignment list. This is the final list of actual beneficiaries assigned at the end of the performance year. CMS uses this list to determine an ACO's shared savings and losses for each performance year.

Andrew, can you tell us about the results of your review?

Sure. Our review covered approximately 9.7 million beneficiaries whom CMS assigned to ACOs in the MSSP during the performance years 2013 through 2015. We reviewed MSSP data related to beneficiaries on the final retrospective beneficiary assignment list. We also reviewed CMS's beneficiary data, including which shared savings program a beneficiary was assigned to and the beneficiary's participation dates in the program.

I want to talk about what CMS must do when assigning beneficiaries. First, CMS must ensure that beneficiaries are assigned to only one ACO in the MSSP. To do so, CMS makes sure that any ACO participant providing primary care services is a participant in only one ACO. Second, CMS must ensure that the MSSP beneficiaries are not assigned to other shared savings programs that provides shared savings payments (for example, Next Generation Model).

Based on the results of our review, CMS complied with Federal requirements when assigning beneficiaries to ACOs in the MSSP by ensuring that MSSP beneficiaries were assigned to only one ACO and were not assigned to other shared savings programs.

How does this work impact the public?

Under Medicare's traditional fee-for-service program, delivery of care is often fragmented because of insufficient incentives to coordinate care and improve quality. Through MSSP, ACO participants are encouraged to coordinate care for their assigned beneficiaries and may also be eligible to receive additional payments if they reduce health care costs and meet certain quality performance standards.

Well thank you Andrew for taking the time to talk to us today.

Thank you for this opportunity.

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