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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Sunshine ACO, LLC, Generally Reported Complete and Accurate Data on Quality Measures Through the CMS Web Portal, but There Were a Few Reporting Deficiencies That Did Not Affect the Overall Quality Performance Score
The Affordable Care Act established the Medicare Shared Savings Program (MSSP). Accountable Care Organizations (ACOs) in the MSSP may be eligible to receive shared savings payments from the Centers for Medicare & Medicaid Services (CMS) if they reduce healthcare costs and satisfy the quality performance standard for their assigned beneficiaries. As part of the standard, ACOs must report to CMS complete and accurate data on all quality measures. For performance year (PY) 2016, ACOs reported more than half of the quality measures using the designated CMS web portal. If the reported data were not complete and accurate, the shared savings payments could have been affected. This vulnerability led us to select two ACOs that had consistently received shared savings payments in order to perform an initial risk assessment of ACOs' reporting of data on quality measures through the CMS web portal. This report covers one of those ACOs.
Investigations Press Release: Former Department of Justice Information Technology Specialist Sentenced to Federal Prison for Possession of Child Pornography
The Centers for Medicare & Medicaid Services (CMS) uses area wage indexes to adjust Medicare payments to reflect local labor prices. CMS calculates new wage indexes annually from wage data (wages, wage-related costs, and hours) submitted by hospitals. We selected Rhode Island Hospital (the Hospital), located in Providence, Rhode Island, for this review because of its potential to significantly affect Medicare payments in its area in Federal fiscal year (FFY) 2019. The Hospital is part of the Lifespan Health System (Lifespan).
Texas Did Not Ensure That Its Managed-Care Organizations Complied With Requirements Prohibiting Medicaid Payments for Services Related to Provider-Preventable Conditions
Federal regulations effective July 1, 2011, prohibit Medicaid payments for services related to treating provider-preventable conditions (PPCs). The Centers for Medicare & Medicaid Services delayed its enforcement of the regulations until July 1, 2012, to allow States time to develop and implement new payment policies. This review is part of a series of reviews of States to determine whether the States ensured that their Medicaid managed-care organizations (MCOs) complied with these regulations for inpatient hospital services.