Accountable Care Organizations and the Fraud and Abuse Laws: Five Ways to Avoid the Pitfalls

Accountable Care Organizations by their very nature are structured in a way that implicates the so-called “Fraud and Abuse Laws.”  ACO provider participants have a financial stake in the organization, refer patients to other providers within the ACO, and share information about patients and practices – all warning flags for running afoul of the fraud and abuse laws.  However, ACOs were created with the explicit purpose of coordinating care for a population of patients to improve outcomes and reduce costs.  To avoid unduly constraining ACO participants’ efforts to provide coordinated care, five waivers to the fraud and abuse laws have been created. This article provides a brief overview of the federal fraud and abuse laws, including the anti-kickback statute, the Stark laws, and the Civil Monetary Penalty laws, along with the corresponding self-implementing waivers to these laws available to ACOs.

Top Five Governance Issues to Consider When Forming an ACO

Among the many issues for consideration when forming an Accountable Care Organization are those related to legal structure and governance.  Here are the top five things to consider in forming an ACO.

Should You Join an ACO?

Let’s say that you are a physician in a primary care practice, and the local hospital has asked you to join an Accountable Care Organization (“ACO”) that the hospital is forming.  What should you do?  Is this a good idea or not?  What questions do you need to ask in order to make an informed decision?

The National Committee for Quality Assurance (“NCQA”), a nonprofit that evaluates and accredits ACOs and other health plans, defines an ACO as “an alliance of physicians, hospitals, and other providers that coordinates care for a particular group of patients to improve quality and reduce costs.”  While improving quality and reducing costs sounds like a good idea, we all know that the devil is in the details.  How do you know whether an ACO is really for you?

Social Enterprise, Health And Wellness, And The Law: A New Frontier

There is a movement afoot in the for-profit social enterprise world and new business forms are being crafted to meet the objectives of these social entrepreneurs.  They may not be right for all businesses; but, for those who want to create what we might call “enlightened profits” the legal community is creating new business formats to assist.  Stay tuned, because this movement will only grow bigger and stronger.

Social Enterprise, Health and Wellness and the Law: A New Frontier

Carson Porter, Rimon PC, Practice Chair

Lara Pearson, Rimon PC, Chief Sustainability Officer

Inna Wood, Rimon PC, Associate

As the late, great soul singer, Sam Cooke, sang: “A change is gonna come…” And here we are in 2012 and change is upon us: changes in the way we deliver healthcare in the U.S.; changes in the way we view personal health and wellness; changes in the way we look at our collective commitment to social good; and, even changes in the legal structures available to those wishing to develop enterprises aiming to positively impact our world.

White Paper: Proposed Rule affecting Accountable Care Organizations

The Patient Protection and Affordable Care of Act of 2010 created a new form of organization called Accountable Care Organizations (“ACOs”). In late March, 2011 CMS issued a Proposed Rule addressing a variety of issues relating to the formation and operation of these ACOs. This white paper addresses some of the more important legal ramifications surrounding ACOs and their participants.