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The Role of Medical Billing in Accountable Care Organizations (ACOs)

Value-based care is gaining traction inside the US healthcare system. Furthermore, the role of medical billing in ACOs is central in offering the main push for steering the industry away from FFS (fee-for-service) and towards value-based care. Regarding medical billing services, ACOs present an exciting model for care services.

Medical Billing in ACOs – Accountable Care Organizations

It is where groups of hospitals, doctors, and other healthcare providers offer high-quality care voluntarily to patients. Such facilities and organizations achieve their goals through help from universal budgeting systems and value-based reimbursements.

Moreover, with adequate care coordination and a mutual/shared savings payment model, the ACOs are improving patient outcomes. This is in addition to a steep improvement in population health management while keeping costs to a minimum.

What should you know about medical billing in ACOs as a medical practitioner? Let’s look into this in detail:

Reward and Risk Scenario

As understandable from the structure of the ACOs, many program providers share in the losses when these groups fail to meet the targeted ACO requirements. In a Medicare-associated program, the participant practices can choose whether to indulge with a one-sided risk or two-sided model.

What is a one-sided risk model?  

In a one-sided risk model, sharing is probable where 50 percent of the cost savings are achievable for Medicare patients.

What is a two-sided risk model? 

It is where the sharing of 60 percent of the cost savings and losses is agreed upon.

Note: It is essential to weigh your options before making your practice revenue vulnerable to any financial hit through the two-sided approach. Your practice needs to consider whether or not your bottom line can sustain the impact.

Change of Payment Models for Medical Billing in ACOs

When taking concerns over medical billing in ACOs, the provider practices must acknowledge that in ACOs the primary focus is more on the shared savings and global fees. Therefore, joining an ACO is synonymous with moving away from the fee-for-service model. Thus, medical practices must prepare to adjust their medical billing approaches accordingly. However, doing so will take your practice one step closer to the future. The US healthcare system is inching away from patient volume to patient value – and this is where the medical billing in ACOs can prove to be a fruitful training ground.

ACO will Bring in New Partnerships

When your practice enters an ACO, you won’t be able to practice in a vacuum anymore. The ACO requirements for coordinated care will bring in new partnerships, which can be uncomfortable for some physicians. Some physicians are incentivized to share referrals within an organization, which can feel like abandoning many professional relationships with your commonly referred colleagues. Thus, it is essential to meticulously evaluate the partners you choose to join forces with, and they will be central towards your success or failure with the ACO.

Importance of Governance with Medical Billing in ACOs

It is further essential to recognize that the governance and leadership of your ACO shall formulate the structure of the organization. Furthermore, the same governance and leadership will decide how resources and patient allocation work among the participating practices. It is important to ensure that, as a provider, you are comfortable with the program management and people. What’s more, you must work to carve a means for having your views/voice heard in the organization-wide discussions.

Final Word

For effective medical billing in ACOs, it is essential to remember that ACOs are much more than only a network of medical providers. The common motive of ACOs is optimization of quality care by better analysis of data, eliminating gaps, and coordinating care across the holistic healthcare continuum. ACOs ultimately target increased patient safety and reduced costs while simultaneously delivering better outcomes for the dollars spent. Most ACOs are groups of specialists, hospitalists, and nursing homes, in addition to other healthcare facilities.

Frequently Asked Questions

ACO strategizes rewards on grounds of providing quality care to patients, while cutting down on necessary spending. ACOs focus on quality of care, on the other hand the MCOs focus on profit generation.
ACOs are a group of healthcare providers responsible for their patients’ total quality of care and cost. In exchange, these providers receive a portion of the savings the organization accumulates.

The ACO is a unique model – in it, physicians, other medical providers, and hospitals come together to deliver coordinated care to patients.