Original Publish Date: October 9, 2018
The exclusivity restrictions of the Medicare Shared Savings Program pose challenges for physician practices that employ nurse practitioners, physician assistants or certified nurse specialists1 and desire to participate in multiple accountable care organizations. Alternatives are available to avoid ACO exclusivity but often require careful planning. This Alert describes ACO exclusivity principles with particular focus on implications and workarounds for group practices that employ nonphysician practitioners.
MSSP regulations preclude a physician group practice2 from being included as a participant in more than one ACO if the group practice submits Medicare claims for various evaluation and management (E/M) or primary care services of primary care physicians, physicians within certain specialties, or nonphysician practitioners. For background on the 2015 revisions to the ACO exclusivity restriction and the methodology for assigning Medicare beneficiaries to ACOs, see our June 9, 2015 alert “Final rule will allow more physicians to participate in multiple ACOs.”
Services billed under any of the following CPT or HCPCS codes are defined as “primary care services” for purposes of assigning Medicare beneficiaries to ACOs and triggering ACO exclusivity:
Billing Codes Implicating ACO Exclusivity
99201-99215 (office or outpatient E/M visits)
99304-99318 (E/M services in a nursing or similar facility, excluding POS 31 modifier)
99319-99340 (E/M services in an assisted living facility or nonmedical residential facility)
99341-99350 (E/M services in a home)
99490 (chronic care management)
99495 and 99496 (transitional care management)
G0402 (Welcome to Medicare visit)
G0438 and G0439 (annual wellness visits)
G0463 (services furnished in ETA hospitals)
Revenue center codes 0521, 0522, 0524 and 0525 submitted by rural health centers (RHCs).
Although the “primary care” label would seem to suggest services under this definition are commonly associated with primary care, these codes are not unique to primary care. In fact, the E/M office and outpatient visit codes within the definition also apply to services of a wide variety of specialist physicians.
ACO exclusivity is triggered with respect to a group practice and its tax identification number when the group submits bills under any of its physicians with a primary specialty designation set forth in the following exclusive specialties list, or any nonphysician practitioners employed or retained by the group practice.
Physician Specialties Implicating Exclusivity
Cardiology, Endocrinology, Osteopathic manipulative medicine
Multispecialty clinic or group practice, Neurology, Addiction medicine
Obstetrics/Gynecology, Hematology, Sports Medicine
Hematology/Oncology, Physical medicine and rehabilitation, Preventive medicine
Psychiatry, Neuropsychiatry, Geriatric psychiatry
Medical oncology, Pulmonary disease, Gynecology/oncology, Nephrology
Primary Care Physicians
Physicians whose primary specialty designation is not included in the above list are not considered in beneficiary assignment, so their services do not trigger ACO exclusivity for their physician practices. In particular, services of physicians in the following specialties (“nonexclusive” specialties) are excluded from assignment and exclusivity determinations:
Physical Specialties Not Implicating Exclusivity
General surgery, pathology, vascular surgery
Allergy/immunology, Plastic and reconstructive surgery, Cardiac surgery
Otolaryngology, Colorectal surgery, Critical care (intensivists)
Anesthesiology, Diagnostic radiology, Maxillofacial surgery
Dermatology, Thoracic surgery, Surgical oncology
Interventional pain management, Urology, Radiation oncology
Gastroenterology, Nuclear medicine, Emergency medicine
Neurosurgery, Hand surgery, Interventional radiology
Hospice and palliative care, Infectious disease, Unknown physical specialty
Opththalmology, Rheumatology, Sleep medicine
Orthopedic surgery, Pain management, Interventional cardiology
Cardiac electrophysiology, Peripheral vascular disease
Exclusivity Implications for Nonphysician Practitioners and Their Group Practices
ACO exclusivity presents particular challenges and potential surprises for specialty group practices. Submitting claims for common office or outpatient visits under the NPI of a nonphysician practitioner will trigger exclusivity for the entire group, even if the group focuses on nonexclusive specialties. Furthermore, there is no minimum threshold for exclusivity, so a single nonphysician practitioner claim can trigger exclusivity for an entire group.
ACO regulations allow physicians within nonexclusive specialties to perform services without affecting a group’s ability to participate in multiple ACOs. Yet, submitting claims for a nonphysician practitioner’s office visits would preclude the group from participating in multiple ACOs. For example, an office visit with a dermatologist, gastroenterologist or orthopaedic surgeon would not trigger exclusivity, but the same visit to one of the group’s nonphysician practitioners for the same condition can trigger exclusivity.
ACO exclusivity has the potential to blindside single specialty “super groups” of specialists who have combined their practices into a single group practice with separate divisions (sometimes referred to as “strategic business units” or “SBUs”). Physicians in separate SBUs may expect to participate in separate ACOs without realizing nonphysician practitioner office visits may prevent participation in multiple ACOs.
In its preamble to its 2015 revisions to the ACO regulations, CMS considered various suggestions for distinguishing between primary care and specialty services of nonphysician practitioners. Such an approach could have allowed nonphysician practitioners to furnish services in some practice settings without triggering exclusivity. CMS, however, decided not to make this distinction. CMS reasoned that most nonphysician practitioners were trained in primary care or provide services in primary care settings, and expressed concern that a special procedure for nonphysician practitioners could create barriers for their involvement in ACOs by imposing conditions that don’t apply to other types of ACO professionals. CMS also noted that nonphysician practitioner services furnished “incident to” a specialist physician would be billed under the specialist’s NPI and therefore excluded from step 1 of the assignment process.
CMS preamble commentary as well as informal comments suggest it may be open to proposals for revisions to address the use of nonphysician practitioners in specialty group practices. Any changes, however, would need to overcome prior CMS objections to distinguishing between nonphysician practitioner primary care and specialty care.
Alternative Structures to Avoid Exclusivity
Physician practices that employ nonphysician practitioners may wish to consider several alternatives to sidestep the exclusivity restrictions and benefit from affiliation with multiple ACOs. In particular, ACO exclusivity can be avoided through “incident to” billing, use of separate Medicare-enrolled TINs, or ACO affiliation without appearing on ACO participant lists.
Failure to consider the implications of nonphysician practitioners on ACO exclusivity can cause unpleasant surprises for group practices. Physician practices that employ nonphysician practitioners and desire to participate in multiple ACOs need to take care in structuring their arrangements to either avoid triggering exclusivity or enter into an appropriate ACO relationships as a nonparticipant.
1 Nurse practitioners (NPs), physician assistants (PAs) and certified nurse specialists (CNSs) are referred to in this Alert as “nonphysician practitioners.”
2This Alert focuses on group practices, although the exclusivity restriction also potentially applies to other health care providers that submit claims for services of physicians or nonphysician practitioners.
Visit the McDonald Hopkins LLC web site at www.mcdonaldhopkins.com.