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The Secretary of the Department of Health and Human Services (HHS) has made available a participation waiver of federal fraud and abuse laws in connection with the operation of accountable care organizations (ACOs) that have entered into a participation agreement under the Medicare Shared Savings Program (MSSP) or the Next Generation ACO (NGACO) Model (hereafter “program models”) with the Centers for Medicare and Medicaid Services (CMS).

Arizona Care Network (ACN) operates two limited liability companies which participate in MSSP (Arizona Care Network, LLC) and the NGACO Model (Arizona Care Network - Next, LLC). ACN has entered into a contract with a comprehensive management services organization where items, services, infrastructure, administration, personnel and facilities, provided directly or indirectly through the joint venture, are disclosed, reviewed, and approved by the board for the purposes of the program models; and for which it intends to qualify for the ACO Participation Waiver. The ACN Participants are individual physicians or group practices that participate in the program models through signed agreements with ACN.

To comply with the ACO Participation Waiver’s requirements, ACN is publicly disclosing the comprehensive management services arrangements as described below. The governing body for each program model has documented its bona fide determination that the arrangements reasonably relate to one or more purposes of the programs. The below referenced arrangements are arrangements for which waiver protection is sought.

Management Services Arrangement

ACO has entered into a Management Service Arrangement (“MSA”) to provide management and administrative support services and staffing. The services are provided directly and, also, through subcontracted arrangements with third parties. The MSA includes the development and maintenance of operational policies and procedures; administration services related to human resources; provision of the information technology hardware, software and services reasonably necessary for the operations of ACO; record maintenance; development of evidence-based initiatives, benchmarks and metrics; program analytics and reporting; and regulatory compliance. The Management Services Arrangement began January 1, 2013.

Care Coordination and Management

ACN provides ACN Participants with staffing to support and facilitate complex care treatment, disease management, transition of care and care coordination, post-discharge follow-up, and preventative care services. Staffing includes registered nurses, licensed clinical social workers, and other unlicensed support staff and liaisons. Support includes phone calls, and visits to the Participant’s office or their patient’s home. In addition, care coordination staff are embedded in offices where the census of patients supports the on-site care coordinators. This arrangement for embedded care coordination began January 1, 2013.

Software Interfaces

ACN through the participating provider arrangement, offers certain Qualifying Software Interfaces to ACN Participants. A Qualifying Software Interface is a software solution that facilitates the extraction of data from the ACN Participant’s electronic health record, claims data, and/or practice management systems. This data extraction supports activities related to care coordination, quality measurement, and population health management, or improvement of the quality or efficiency of health care delivery among parties. These arrangements for software interfaces began January 1, 2013.

Clinical Integration Platforms

Clinical Integration Platforms are used for collaboration and the secure distribution of datasets as it relates to the ACO’s patient population. These platforms allow ACO to collaborate with ACO Participants, business associates, and other providers participating in the care of ACO Participant patients on operational, financial and clinical improvement activities.

The Clinical Integration Platforms include secure data storage, web-based interfaces, and static or dynamic reporting to support the following ACO activity:

  • Population health management;
  • Coordination of care;
  • Access to electronic medical records by and among providers in different care settings;
  • Referral management;
  • Reporting related to Participation requirements and metrics including quality of care, and operational efficiencies; and
  • Provision of gap reporting, patient summaries, risk stratification, and enhanced registry services.

The Clinical Integration Platform arrangements began January 1, 2013.

Clinical Documentation Improvement (CDI) Program

This Program was created for the purposes of ensuring complete and compliant clinical documentation practices across ACN. ACN provides support, including training and education to ACN participants to facilitate improvement in clinical documentation. This arrangement will lead to more accurate risk scoring and identification of ACN’s patients, including ACN-assigned Medicare beneficiaries that can benefit from care interventions. This will assist the ACN in improving and meeting quality performance standards of the program models. The Clinical Integration Platform arrangements began January 1, 2013.

Chronic Care Management Equipment and Services

ACN provides certain Chronic Care Management Equipment and Services to ACO Participants and their patients. ACN seeks to provide beneficiaries with items and services that advance the goals of preventive care, adherence to treatment, drug, or follow-up care regimes, or management of a chronic disease or condition. Chronic Care Management Equipment and Services are provided through vendors that specialize in the management of chronic conditions such as diabetes, asthma, or chronic obstructive pulmonary disease. These programs include the provisioning of testing supplies, monitors, and equipment that facilitates the submission of clinical data to the vendor and allows the patients to receive self-management and health coaching services. The program also produces reports that are used by the ACN Participants in the treatment of individual patients as well as data analysis for the ACN quality improvement programs. These arrangements began January 1, 2013.

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