Next Generation Accountable Care Organization (NGACOs)

The NGACO Model offers Accountable Care Organizations (ACOs) the option to participate in a payment model called All-Inclusive Population Based Payment (AIPBP) where the ACO will take the responsibility for entering into payment arrangement with their providers and paying claims instead of Medicare paying it through the Fee-for-Service (FFS) program.

The goal here is to establish a monthly cash flow for the AIPBP participating ACOs through a mechanism called the Next Generation Participants and Preferred Providers. The plan is that the AIPBP builds on population based payments in the NGACO Model but actually allows for more flexibility in establishing payment relationships between the ACO and their providers.

So to establish a monthly cash flow, under the AIPBP a participating ACO can receive a monthly lump-sum payment for those providers that have entered into a written agreement for AIPBP Payment Arrangements. The monthly payment will be based on an estimation of the care that the provider will deliver to the beneficiary in the performance year by AIPBP participating providers. These lump-sum payments will be reconciled after the performance year so they can balance out the monthly payments against what AIPBP participating providers would have received under the Fee-for-Services program.

Providers will continue to submit Fee-for-Service claims to Medicare, but payments will not be made on these submissions to providers that signed-up to participate AIPBP (outside of add-on payments for inpatient hospitals (outlier, disproportionate share, IME, new technology and Islet isolation cell transplantation payments). If a provider does not have an AIPBP Payment Arrangement in place with an ACO, they will continue to receive Fee-for-Service payments for all of the patients/beneficiaries they treat.

Providers will continue to submit all Fee-for-Service claims to CMS and CMS will make coverage and liability determinations and assess beneficiary liability. Beneficiary liabilities will be calculated based on what Medicare would have paid the provider if they were not involved with an AIPBP. Medicare Summary Notices (MSN) should reflect the amount that would have potentially been paid. Providers in the AIPBP will continue to receive MSNs.

For more information on this topic, feel free to visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17011.pdf

Provided by Kevin Harrington, MATS, MSHA, RHIA, CHP  Faculty, Saint Joseph's College