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Sunshine ACO, LLC, Generally Reported Complete and Accurate Data on Quality Measures Through the CMS Web Portal, but There Were a Few Reporting Deficiencies That Did Not Affect the Overall Quality Performance Score

Why OIG Did This Review

The Affordable Care Act established the Medicare Shared Savings Program (MSSP). Accountable Care Organizations (ACOs) in the MSSP may be eligible to receive shared savings payments from the Centers for Medicare & Medicaid Services (CMS) if they reduce healthcare costs and satisfy the quality performance standard for their assigned beneficiaries. As part of the standard, ACOs must report to CMS complete and accurate data on all quality measures(Quality measure: A standardized method of assessing the quality of care furnished by ACOs. The overall quality performance score is a value that is based on reported data on quality measures and is used to calculate the shared savings payments.). For performance year (PY) 2016, ACOs reported more than half of the quality measures using the designated CMS web portal. If the reported data were not complete and accurate, the shared savings payments could have been affected. This vulnerability led us to select two ACOs that had consistently received shared savings payments in order to perform an initial risk assessment of ACOs' reporting of data on quality measures through the CMS web portal. This report covers one of those ACOs.

Our objective was to determine whether Sunshine ACO, LLC (Sunshine), complied with applicable Federal requirements when reporting data on quality measures through the CMS web portal.

How OIG Did This Review

We limited our review to Sunshine's data on nine quality measures reported through the CMS web portal for PY 2016. We reviewed a stratified random sample of 240 beneficiary-measures.

What OIG Found

For 229 of the 240 sampled beneficiary-measures, Sunshine complied with applicable Federal requirements by reporting complete and accurate data on quality measures through the CMS web portal. However, for the remaining 11 sampled beneficiary-measures, Sunshine did not comply with requirements. Specifically, the medical records did not support that the beneficiaries (1) should have been either included in or removed from the measure population(Measure population: Beneficiaries (from the sample that CMS provided) for whom CMS measured the quality of care furnished by the ACO through the use of quality measures.) based on the exclusion criteria (Exclusion criteria: A medical condition or a situation that would require removal of a beneficiary from a measure population before reporting whether the conditions of a quality measure were satisfied for a beneficiary (e.g., having a diagnosis or past history of total colectomy or colorectal cancer that would require removal of a beneficiary from the measure population for Colorectal Cancer Screening).) or (2) satisfied the conditions of the quality measures(Conditions of a quality measure: Required outcomes or processes (e.g., receiving a pneumococcal vaccination) for beneficiaries who were included in a measure population. ). Further, the medical records did not support the reported measurement values(Specific values (e.g., a beneficiary's blood pressure reading on a given date) used to determine whether certain conditions were satisfied for a beneficiary.) or that the reported measurement values were the most recent for the beneficiaries. Instead, the records supported different measurement values that would have still satisfied the conditions of the quality measures.

These reporting deficiencies, which did not affect Sunshine's overall quality performance score, occurred because according to Sunshine officials, the ACO staff made clerical errors when entering the data and did not perform a thorough review of the beneficiaries' medical records to confirm that (1) the beneficiaries should have been included in or removed from the measure population for the Colorectal Cancer Screening measure or (2) the reported measurement values were the most recent for the Controlling High Blood Pressure measure and the Diabetes: Hemoglobin A1c Poor Control measure.

In written comments on our draft report, Sunshine did not provide any information regarding our findings and conclusions.

What OIG Recommends

Effective May 31, 2019, Sunshine voluntarily terminated its participation in the MSSP before the end of its agreement period, which was from January 1, 2017, through December 31, 2019. Accordingly, this report contains no recommendations.

Filed under: Centers for Medicare and Medicaid Services