Accountable Care Organization Medicare Shared Savings Progam

Recently our firm was retained by a Private Equity firm to access the ACO market and two potential acquisitions that provide ACO outsourced services and Health Care IT solutions.

Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) have a special, limited opportunity to innovate.   Waivers exempting MSSP ACOs from certain legal requirements and other benefits enable MSSP ACOs to experiment within certain limits.    The Medicare Shared Savings Program requires 33 measure that must be self-reported by the ACO to CMS. After  a limited period, self-reporting will not be allowed and third parties will be required to perform reporting.

The “MSSP 33” present interesting analytic opportunities, in particular for new cloud based analytics firms who provide flexible, low initial capital outlay to get started using Software as a Services (Saas) business models.  The MSSP 33 will be impacted by ICD-10 and other changes to data standards in healthcare within the next 12 months.

According to the Centers for Medicare and Medicaid (CMS), as of May 2014 there were 338 ACOs in the MSSP program with 4.9 million beneficiaries. Seventy two percent (72%) were in metropolitan areas.

ACOs were split into these categories:

  • Networks of Individual Practices
  • Group Practices
  • Hospital / Professional Partnerships
  • Hospital employing ACO professionals
  • Federally Qualified Health Center
  • Rural Health Clinic
  • Critical Access Hospital
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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.