CMS Loosens Restrictions on Telehealth for Certain Shared-Risk ACOs

Accountable Care Organizations who are at risk of owing money back to Medicare because they haven’t met spending targets on shared-risk beneficiaries now have more freedom to use telehealth.

Under a guidance document released last month by the Centers for Medicare & Medicaid Services, ACOs participating in a Medicare Shared Savings Program that is under two-sided risk and who have selected prospective payment can remove geographic limitations normally applied to fee-for-service plans and allow beneficiaries to receive certain telehealth services at home.

“CMS allows clinicians in applicable ACOs to begin providing and receiving payment for covered telehealth services to prospectively assigned beneficiaries without geographic restriction, including, for many services, where the originating site is the and in beneficiary’s home,” the agency said in a fact sheet on the new rules, which took effect on January 1. “There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can provide these covered telehealth services and bill Medicare according to existing telehealth billing rules.”

CMs has been slowly – some would say too slowly – working to give ACOs more flexibility to use telehealth and mHealth platforms since passage of the Bipartisan Budget Act of 2018, which opened the door to connected health under section 1899(I) of the Social Security Act.

While all ACOs in two-sided risk models who use prospective assignment are free to use telehealth, CMS is now loosening the reins for those ACOs that are at risk of paying money back to CMS because they haven’t hit their spending targets on patients for which they’re financially responsible.

Risk-based ACOs that participate in the preliminary prospective assignment with retrospective reconciliation method do not qualify, CMS said, because final assignment isn’t determined until the end of the performance year.

“(A)pplicable ACOs are those with prospective assignment for a performance year in the ENHANCED track (including existing Track 3 ACOs), BASIC track levels C, D, or E, or in the Track 1+ Model,” the agency said.

According to the National Association of ACOs (NAACOS), about one-fifth of the 517 ACOs in the Medicare Shared Savings Program are able to use telehealth more freely under the new guidelines.

NAACOS has pointed out that the new rule isn’t specific on what telehealth services are “appropriate” to be delivered to the beneficiary’s home, and has asked CMS for clarification.