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Life Health > Long-Term Care Planning

PPACA: Feds Seek ACO, Review Comments

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Federal agencies are asking for public comments about the new accountable care organization (ACO) and federal external health plan decision review programs.

The federal Centers for Medicare & Medicaid Services (CMS) is planning to publish a major request for information (RFI) on ACOs Wednesday in the Federal Register, and the Employee Benefits Security Administration (EBSA) plans to join with the U.S. Department of Health and Human Services PPACA Toolkit(HHS) to publish a major federal external review program RFI in the same Wednesday, according to preliminary versions of the RFIs.

The agencies are issuing the RFIs to implement provisions of the Affordable Care Act, the legislative package that includes the Patient Protection and Affordable Care Act (PPACA).

The accountable care organization (ACO) RFI will focus on a move to make ACOs part of the Medicare provider community.

An ACO is a vehicle for paying teams of health care providers to care for whole patients, instead of paying for care one service at a time.

In the past, the federal government tried to hold down rising health care costs by imposing strict limits on health care providers’ financial relationships with other providers.

The Affordable Care Act includes provisions that require CMS to work with ACOs and give federal agencies the authority to keep antitrust laws, anti-kickback laws, and similar laws from interfering with ACO operations.

Many private health insurers have been experimenting with ACO programs, and experts believe the Medicare ACO program could influence the private carrier ACO efforts.

In the ACO RFI, CMS officials will ask about policies it should adopt to help solo practitioners and small groups participate in ACO programs, strategies for linking Medicare beneficiaries to ACOs, and methods for assessing care quality, beneficiary experience and caregiver experience.

In the other RFI, the external review program RFI, EBSA and the Office of Consumer Information and Insurance Oversight (OCIIO), an HHS agency, will be

asking for ideas about how to set up a federal program for reviewing health plan review denials.

The Affordable Care Act encourages states to set up review programs. In a states without a review program, the federal government is supposed to handle reviews.

EBSA and OCIIO officials note that the government might hire contractors to handle the reviews.

In the RFI, officials will be ask about the standards that apply to existing “independent review organizations” (IROs), the kinds of infrastructure that IROs now have and would need to run a federal review program, and IRO data security programs.

Officials also will ask about special considerations for IROs that would handle coverage questions, questions of medical necessity and questions relating to experimental treatments.

Officials also will ask about the best way to grade the IRO graders.

“What specific requirements should be applied to IROs to evaluate progress toward performance goals?” officials plan to ask. “What performance goals are the most appropriate?”


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