Expert Perspective

April 23, 2020

COVID-19 and the Impact to ACOs and Risk-based Contracts

Joe Nicholson, III, DO – Chief Medical Officer

Successfully managing your practice during the COVID-19 public health crisis requires being aware of the potential implications associated with the government and industry programs you are participating in. Staying up to date on the processes and information coming from insurance partners is also important.

In particular, practices that have joined accountable care organization (ACO) programs and entered into risk-based arrangements may find themselves especially vulnerable as they devote more resources to the COVID-19 response.

The impact is far reaching. According to a Health Care Payment Learning & Action Network (LAN) report, during 2018, 35.8% of U.S. healthcare payments and 77% of the covered population flowed through LAN category 3 and 4 alternative payment models (APMs). Category 3 stakeholders includes APMs built on fee-for-service architecture and category 4 covers population-based payment.

Provider organizations across the nation have stepped up to bring attention to the potential impact of high costs associated with COVID-19 efforts and recommend taking action to help ensure clinicians and practices aren’t penalized inappropriately moving forward.

Letters from America’s Physician Groups (APG) and other organizations such as the National Association of ACOs (NAACOS) provide recommendations for the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare & Medicaid Innovation (CMMI) to consider what could provide relief and flexibility during the public health emergency response.

If enacted, these measures may offer much-needed support to providers throughout the country in the coming months.  We invite you to stay informed on this important issue. APG provides resources and daily updates to help keep physicians informed on the COVID-19 public health emergency.

Resources and Updates from Insurance Partners

Several payer organizations have published updates and guidance around billing and reimbursement during the coronavirus response effort. Several are waiving certain costs associated with COVID-19 screening, for example, or have updated telehealth reimbursement policies.

Cigna Coronavirus (COVID-19) Interim Billing Guidance for Providers for Commercial Customers
Cigna offers COVID-19 billing and reimbursement guidance to help ensure providers can keep delivering care while getting properly reimbursed for services. The site important information such as:

  • Virtual care guidelines
  • General billing guidance for COVID-19 and non-COVID-19 services
  • Virtual care for physical, occupational, and speech therapy services

BlueCross BlueShield Coronavirus (COVID-19) Updates

Access information and updates related to COVId-19 from BlueCross BlueShield here. The site includes state-specific updates for COVID-related treatment, telehealth, prescriptions, and more.

Humana Coronavirus disease 2019 (COVID-19)

Humana has published information and resources to help providers manage processes related to COVID-19 on its website, including guidance for:

  • Telehealth
  • Administrative updates
  • Diagnosis and procedure codes
  • Pharmacy providers
  • Patient benefits, resources

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