Checklist With VBC Knowledge is Power and Maybe Savings

Last week, an employer I was speaking with on my favorite subject, value-based care, made the comment, “None of my carriers are charging me any ACO fees.” I didn’t want to be a wet blanket, but I had to point out that unfortunately this was most likely not the case. So how does it happen that an employer might not know about fees for value-based care? And what should they do about it?

The national carriers all have Accountable Care Organization (ACO) or Patient Center Medical Home (PCMH) contracts with physician or provider groups embedded within their broad PPO networks. Members who frequently utilize physicians from these groups are deemed “attributed” to the group,  and their plan sponsor is assessed a care-coordination fee and/or shared-savings payments. In some cases these charges appear on an invoice, but in other cases they are deducted directly from the employer’s ASO bank account. Many employers are not even aware that this is happening.

So what should you do? The answer is simple – ask!

  • Request a summary report listing the number of attributed members and value-based care charges paid (typically care coordination fees and shared savings bonuses)
  • Request reporting on the cost and quality outcomes for members who are attributed to an ACO or PCMH
  • Obtain carrier agreement to provide this reporting on a routine basis, for example, as part of quarterly dashboards or annual plan reviews
  • Ask what guarantees are available regarding performance of these provider groups;  some carriers will refund care coordination fees

The first step is asking the right questions. Don’t give up if you have trouble deciphering the responses. You have the right to know what you are being charged and if you are getting value for the money.

This post is part of our 2017 Planning Checklist series.

Molly Loftus
by Molly Loftus

Chief Actuary, Health & Benefits, Mercer

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