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Inherent in their design, Accountable Care Organizations (ACOs) are responsible for the total care of their assigned patient population. Their savings are based on the overall quality, quantity, and cost of care their beneficiaries receive. This alone is no easy feat. Yet, for those ACOs participating in Centers for Medicare and Medicaid Services (CMS) programs, there is an added complexity that commercial ACOs do not face.
Within these CMS programs, ACOs cannot mandate beneficiaries seek care only from affiliated providers. In addition, these ACOs cannot utilize prior authorization to deny care (for example, new expensive treatments without demonstrated outcomes). This leaves ACOs particularly vulnerable to wasteful spending or bad actors perpetuating fraudulent spending.
As described in recent headlines, these ACOs stand by watching the impacts of fraud or waste across their population with no recourse. Any potential relief comes in the form of legislative rulemaking or CMS policies, both of which take time to create and work their way through the approval process. They also do not provide guaranteed relief of this spend, particularly if it is not fraudulent and “simply” wasteful.
In the post below, we highlight the data behind these headlining fraud and waste stories, as well as ways ACOs can mitigate impacts.