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Deciphering ACO Exclusivity for Specialist Physicians Print E-mail
Written by Frederick Segal, Stephen Siegel   
Friday, 29 June 2012 08:24

On November 3, 2011, the Centers for Medicare & Medicaid Services (CMS) published the "Final Rule" setting forth the parameters for Accountable Care Organizations (ACOs) to participate in Medicare Shared Savings Program (MSSP). One of the concerns of specialist physicians who are interested in joining an ACO is their ability to participate in more than one ACO. In the Final Rule, CMS included provisions that provide flexibility for specialists to participate in multiple ACOs. However, practically speaking, they may not have as much flexibility as the Final Rule appears to provide. This article discusses a practical problem specialist physicians face if they seek to participate in multiple ACOs.

The Final Rule defines an ACO as a legal entity that has a certain Taxpayer Identification Number (TIN), and which is comprised of one or more "ACO participants". An ACO participant is an individual or group of provider(s)/supplier(s) (e.g. hospitals, physicians, and others involved in patient care) that are identified by a Medicare-enrolled TIN. An ACO provider/supplier is defined as a provider or supplier who is enrolled in the Medicare program and bills on a fee-for-service basis under a billing number assigned to an ACO participant's TIN.

As part of its application to CMS, a prospective ACO is required to submit a list of its ACO participants and their associated ACO providers/suppliers, and identify those providers/suppliers who are primary care physicians. Further, the ACO participants and the providers/suppliers are, prior to the filing of the ACO application, required to sign agreements or contracts relating to participation in the ACO. Essential to the successful operation of the MSSP is CMS' ability to gather and analyze claims and other information submitted to CMS by an ACO participant through its billing TIN. This data will be used by CMS to calculate an ACO's shared savings, assign beneficiaries, benchmark, etc. Consequently, CMS has determined that all ACO providers/suppliers associated with each ACO participant TIN must agree to participate in the ACO as a member of that ACO participant. Thus, for example, if a group practice agrees to participate in an ACO, the group practice entity will be designated as an ACO participant and all of the physicians and allied health professionals in the group must agree to participate in that ACO. CMS's "all or none" approach is one reason why physicians and physician group practices may hesitate before agreeing to become either ACO providers/suppliers or ACO participants.

An ACO participant TIN, and its associated physicians "upon which beneficiary assignment is dependent," must be exclusive to one ACO. If beneficiary assignment is not dependent on the ACO participant's TIN, an ACO participant and its associated physicians may participate in multiple ACOs. Thus, the question of how Medicare beneficiaries will be assigned to an ACO becomes a critical step in determining whether a given ACO participant is able to provide services on behalf of multiple ACOs.

The assignment of a Medicare beneficiary to a particular ACO is a two-step process... READ MORE 

Mr. Segal and Mr. Siegel are attorneys at Broad and Cassel in Miami, FL.
Last Updated on Monday, 02 July 2012 10:12
The Top 3 MRA Mistakes Print E-mail
Written by M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC   
Sunday, 24 June 2012 00:00

How Much Are They Costing Your Practice?

When a medical group's risk score is low despite a chronically ill patient population, the culprit is generally one of three very common practitioner habits:

1.       Failure to connect diabetic manifestations

2.       Improper documentation of histories

3.       Un-specific cardiac disease

Let's explore each one...  Click  HERE to finish the blog post.

About the authors: M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC are principals at Coleman Consulting Group. The firm's services include:

·          Risk Adjusted Reimbursement (MRA)
·          Coding & Billing
·          ICD-10-CM Consulting & Training
·          EMR/Meaningful Use Attestation
·          Credentialing & Contracting

For additional information about the firm or to request a complimentary no-obligation consultation, please call 954.578.3331 or email

Last Updated on Monday, 25 June 2012 07:16
Domestic and International Healthcare Arbitrations Print E-mail
Written by   
Thursday, 14 June 2012 00:00

Health care companies are increasingly resorting to arbitration, instead of courtroom litigation, to settle their disputes. Both the number and diversity of matters going to arbitration are on the upswing. From provider-payor issues, to licensing disputes, to M&A deals, sophisticated parties elect arbitration with the expectation that they can resolve their differences in confidence with less expense. This article provides practical advice to health care companies on whether to choose to arbitrate, how to draft arbitration agreements and how to conduct arbitrations. It addresses both U.S. and cross-border arbitrations. This article was featured in the March 25, 2012 issue of Health Lawyers Weekly.

Click here to read the full article.

Last Updated on Friday, 15 June 2012 11:14
Alcohol Abuse vs. Dependence: Is it Fraudulent to Knowingly Soft-Pedal a Diagnosis? Print E-mail
Written by M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC   
Sunday, 03 June 2012 00:00

Do you think a provider would chart heart disease for a patient with - say - hypertrophic cardiomyopathy because it's a 'warmer, fuzzier' diagnosis? Or try to scare a patient with metabolic disorder into losing weight by diagnosing her prematurely with diabetes?  You're probably shaking your head in disbelief, yet some providers do just this when it comes to charting dependence on a substance, such as alcohol or other drugs. Their ambivalence leads to documentation of 'use' or 'abuse' as they fear "stigmatizing" the patient with a diagnosis of addiction, and somehow 'use' and 'abuse' seem less negative. 

Clinicians are ethically mandated to use their medical knowledge and judgment to diagnose a patient's condition and then to chart it completely and accurately.  So if our hypothetical provider charts in this fashion, is he, in a sense, committing fraud?  Fraud has several definitions:  deceit, trickery, sharp practice, or breach of confidence, perpetrated for profit or to gain some unfair or dishonest advantage; any deception, trickery, or humbug.

While soft-pedaling a diagnosis hardly results in profit or gain, it is dishonest, and in keeping with the definition above, deceitful. It begs the question of where exactly is the line between accurate reality and a little white lie. Knowingly charting less than accurately is deceptive and fraudulent.

 Click here to read more.

About the authors:  M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC are principals at Coleman Consulting Group. The firm's services include:

-Risk Adjusted Reimbursement (MRA)             
-Coding & Billing
-ICD-10-CM Consulting & Training                   
-EMR/Meaningful Use Attestation
-Credentialing & Contracting

For additional information about the firm or to request a complimentary no-obligation consultation, please call 954.578.3331 or email

Last Updated on Monday, 04 June 2012 08:51
Give the Government Their Own Medicine: Make Up for Declining Reimbursements with Financial Efficiency & Tax Savings Print E-mail
Written by Carole C. Foos, CPA & David B. Mandell, JD, MBA   
Sunday, 29 April 2012 00:00

Recent Medicare cuts in reimbursements for most physicians and coming changes from the healthcare overhaul are making it more difficult for physicians to prosper. There are "top line" tactics for procedures and billing that can increase revenues. However, this article will address "bottom line" strategies, how the practice produces wealth for the doctor-owner. Specifically, two strategies to save in taxes what may be lost in reimbursement will be covered.

Using the Ideal Corporate Structure

Choosing the form and structure of one's medical practice is an important decision that can have a direct impact on financial efficiency and the state and federal tax burdens. Several issues to consider are:
  • Utilize a Partnership or Proprietorship. While these entities are asset protection nightmares and can be tax traps for physicians, they present a tremendous opportunity to recoup some reimbursement losses through lower taxes.
  • Do Not Treat an "S" Corporation as a "C" Corporation.   Approximately 60%-70% of all medical practices are estimated to be "S" corporations. Unfortunately, inefficient compensation structures can completely erase the tax benefits of having the "S" corporation.
  • Implement a "C" Corporation. This corporate structure has declined for medical practices, likely due to the "double tax" problem of corporate and individual taxes. While this is crucial to the proper use of a "C" corporation, there are tax-deductible benefit plans available only to "C" corporations that could counter many of the proposed reimbursement cuts.
  • Use Multiple Entities. Very few medical practices use more than one entity for the operation of the practice. Successful practices can often benefit from a superior practice structure that includes both an "S" and a "C" corporation to reap both tax reduction and asset protection benefits.
Maximizing Tax-Deductible Benefits for Doctors in a Practice

Benefit planning can help reduce taxes, but inefficient plans that are deductible to the practice may be too costly for the doctor-owners. To create an efficient benefit plan, physicians need to combine qualified retirement plans (QRPs), non-qualified plans and "hybrid plans." QRPs include 401(k) s, profit-sharing plans, money purchase plans, defined benefit plans, 403(b) s, SEP or SIMPLE IRAs, and other variations. While contributions to these plans are typically 100% tax deductible and the funds are afforded excellent asset protection, many QRPs are outdated and are only one piece of puzzle.

The Pension Protection Act recently improved the QRP options for many doctors, allowing additional contributions and deductions. Maximizing QRP options under the new rules could increase deductions significantly for a tax year. Additionally, fringe benefit plans, non-qualified plans and "hybrid plans" enjoy favorable short-term and long-term tax treatment.

With the current and upcoming reimbursement cuts, tax and efficiency planning must be a priority.

The authors welcome your questions and can be contacted at (877) 656-4362 or through the website  David Mandell, JD, MBA is an attorney, author of 5 books for doctors, and principal of the financial consulting firm OJM Group, where Carole Foos, CPA works as a CPA and tax consultant. They can be reached at  Please click HERE to read important disclosures.
Last Updated on Sunday, 27 May 2012 15:58
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