Avoiding Exclusivity: Participating in Multiple ACOs
There are affirmative steps rheumatologists and group practices can take to avoid exclusivity under the ACO regulations and enhance their ability to participate in multiple ACOs.
Billing Under Separate TINs: One way for rheumatologists to increase the probability of participating in multiple ACOs is to furnish services under a separate entity that bills under a separate TIN, rather than billing the services under the TIN associated with the group practice. One way to accomplish this separation is to provide some services under a professional services or employee leasing agreement with a hospital or other healthcare provider that bills for the services under its TIN. Other options include forming a separate entity to retain physicians and bill for their services, or allowing physicians to work part time for other healthcare entities. Another option is for a physician to enroll and bill under his or her Social Security Number.
Billing under separate TINs or under the physician’s Social Security Number is a start, but is subject to limitations and pitfalls. Arrangements using multiple TINs or a physician’s Social Security Number should be carefully structured so as to comply with contractual obligations and legal requirements. In particular, healthcare entities whose physicians split their practices between multiple entities may find it difficult to avoid the reimbursement restrictions of the antimarkup rule or to satisfy the Stark Law “group practice” definition and in-office ancillary services exception. Logistically, billing through multiple entities can complicate the administrative responsibilities for the practice’s office personnel and billing company. For example, if a rheumatologist bills under multiple TINs within a single group practice, it may be challenging for the office personnel to ensure that records and billings reflect the appropriate healthcare provider for each patient. An additional concern is that the use of multiple TINs may require written consent by third parties (e.g., payers) in order to avoid breaching contractual and fiduciary obligations.
Billing Under Different Codes: Rheumatologists should also consider whether they can appropriately bill for certain services under billing codes that are not “primary care services” as defined under the ACO regulations. For example, office visits may be billed as part of a global fee for a procedure. In many cases, however, billing under multiple codes may be limited, as it may require the group practice to forego reimbursement for part of the services performed.
Until the Centers for Medicare and Medicaid Services amends or interprets the ACO regulations to provide greater flexibility, rheumatologists will continue to run some risk by participating in multiple ACOs. In light of the legal landscape for ACOs and specialist physicians in particular, careful consideration and planning is imperative for rheumatologists seeking participation in multiple ACOs.
