Managing Contract Alignment and Attribution

One of the most frequently asked questions from my ACO REACH and MSSP ACO organizations is how to identify Medicare beneficiaries who were not aligned to their ACO. For some Medicare beneficiaries, there are ways to know why they were not aligned that are actionable for the ACO. For some, CMS does not release the rationale for the specific beneficiaries. Understanding the files and codes that CMS releases is key to finding the actionable beneficiaries for the ACO.

CMS releases a set of files for the claims and beneficiary data on monthly and quarterly basis. ACO REACH and MSSP ACO organizations receive CCLF files, which stands for Claim and Claim Line Feed. These files have claims data for aligned and potentially alignable patients. MSSP ACOs then send a few additional files with information about data sharing and reasons why specific patients were not aligned to the MSSP ACO. The Table 1-1 and Table 1-5 files are released after the end of a quarter to confirm who was aligned (Tabe 1-1) and exclusions (Table 1-5) with additional information updated monthly (BNEX file). For ACO REACH organizations, the Beneficiary Assignment Report (BAR) is released monthly with updates to patients who are no longer actively attributed. At times, CMS takes an extended period to enter that a beneficiary has died which results in patients who have died in the previous performance year are often included in the alignment for the ACO for all programs. Patients are only added to the attribution and alignment monthly, but they can be removed monthly depending on the reason for removal.

In all cases I have witnessed, the CCLF8 files include many beneficiaries who are not aligned or attributed to the ACO without CMS providing a reason for why the beneficiary is not aligned. But for many others, there are reasons that the beneficiaries are excluded that are released on a regular basis. 

MSSP ACO exclusion codes from Table 1-5:

• AB R01 = the patient had at least one month that they did not have either Part A or Part B Medicare coverage
• NO US R02 = the patient does not reside in the US
• HMO R03 = the patient had at least one month in a Medicare Advantage plan (HMO)
• MDM R04 = the patient is attributed to another Medicare Shared Savings program 
• PLUR05 = the patient did not receive the plurality of primary care services from the ACO 
• NOFND R06 = the patient either did not have a primary care service billed by an ACO physician (MD or DO) during the year or other reason not listed

MSSP ACO exclusions from BNEX file:

• BD = Beneficiary Declined – beneficiary is still aligned and attributed to the ACO but is not data sharing through CMS
• BR = Beneficiary Removed – beneficiary is not attributed or aligned without additional information
• EC = Excluded by CMS – beneficiary is not attributed or aligned without additional information
• PC = No Practitioner Service Exclusion – beneficiary did not see a participant practitioner who is a part of the ACO
• PL = Participant List Changed – the ACO has changed the participating provider list which has removed the patients who are aligned to the provider who is no longer with the ACO

ACO REACH codes from Beneficiary Assignment Report (BAR):

• AB = beneficiary lost either Medicare Part A or Part B coverage
• AL = beneficiary is aligned
• CO = beneficiary moved outside of the ACO REACH service area
• DD = died in the previous performance year and still in this years’ alignment
• DY = died in current performance year and still in this year’s alignment
• EM = for Voluntarily Aligned beneficiaries, either did not have any claims with an ACO REACH provider during the performance year and had at least one qualified Primary care Qualified Evaluation & Management (PQEM) claim during the performance year from a non-ACO REACH affiliated provider 
• EP = beneficiary is aligned to another Medicare Shared Savings initiative
• MC = beneficiary transitioned to Medicare Advantage (HMO)
• MS = beneficiary transitioned to a Medicare as a Secondary Payer
• OU = beneficiary resided in a non-US location for any month during the performance year
• NV = beneficiary’s eligibility cannot be verified

When the codes for exclusion are understood, it becomes easier to identify which beneficiaries can be attributed to the ACO. One easy fix for MSSP ACOs is reviewing the beneficiaries who did not receive a visit during the performance year from a participating provider in the ACO who is either an MD or DO. This is an important distinction from ACO REACH contracts which do not have the requirement for an MD or DO visit during the year and is one that can easily be overlooked. Plurality of care is often a concern when a beneficiary has an extended stay at a skilled nursing facility (SNF) after a hospitalization. Being aware of the attributed beneficiary’s transitions through the acute to post-acute healthcare system can assist with awareness of risk of loss of attribution due to plurality. Contracting with SNF providers to cover the ACO’s patients while in a SNF can assist with loss of plurality. Also, reviewing who else is seeing your beneficiaries and determining if there is a reason for the “leakage” that can be rectified. Beneficiaries who are a part of another Medicare Shared Savings program can be spoken to about voluntary alignment to your organization’s ACO but be certain to have a provider in the ACO see the beneficiary for a PQEM visit within the performance year. 

Unfortunately, we never have the totality of the data from CMS on all potential aligned and attributed beneficiaries to the ACO REACH or MSSP ACO. But for those who we do have the data and it is actionable, it is worth reviewing for potential opportunities to add to the ACO’s aligned and attributed beneficiary count. It is always essential to review the regulations sent by CMS for the ACO REACH and MSSP ACO contracts to ensure that the correct specialty taxonomies and CPT codes will contribute to alignment are utilized. 

For more information on Managing Contract Alignment and Attribution, or anything ACO-related, feel free to set up a quick meeting.

Author:

Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions