By: Carlos Arce
If you’re a healthcare provider working under DCE (ACO Reach or ACO MSSP models), you’ve likely experienced the unique challenges of shared savings agreements. These programs can be a fantastic tool for improving care coordination and reducing costs, but as an attorney who has worked extensively in this field, I’ve seen firsthand how complex and frustrating these agreements can become.
One of the most common issues providers face is the denial of their shared savings payments, even when they believed they met the performance and contractual requirements. Unfortunately, these denials usually stem from two primary reasons:
· Contractual Performance Allegations: The ACO may claim that the provider failed to meet specific benchmarks outlined in the agreement, even in cases where the provider has upheld their end of the deal.
· Withholding Payments for Departing Providers: This often feels like a punitive measure. If you’ve decided to leave an ACO, you may find your payments withheld, with little transparency or explanation provided.
If either of these scenarios sounds all too familiar, you’re not alone.
What You Can Do to Protect Yourself
I often counsel providers in these situations, and here’s what I typically recommend to ensure you’re not left without the compensation you’ve earned:
· Understand Your Contract: Before signing any ACO agreement, ensure you and your legal counsel review the terms in detail. This includes payment timelines, performance benchmarks, and any clauses tied to program departure.
· Document Everything: Keep detailed records of your performance, patient outcomes, and compliance with all obligations under the ACO’s requirements. The more data you can provide, the stronger your case if a dispute arises.
· Communicate Regularly: Proactively communicate with your ACO throughout the performance year to confirm you are meeting their expectations. Regular check-ins can help address potential issues before they escalate.
· Seek Legal Support Early: If you suspect your payments may be at risk, consult an attorney experienced in ACO agreements as soon as possible. They can help you understand your rights and potentially negotiate on your behalf.
What frustrates me most about these disputes is how frequently they could be avoided with greater transparency and collaboration. Providers dedicate their work to improving patient outcomes and reducing costs, often at the expense of significant time and effort. When payments are withheld or denied, it’s not only discouraging but also deeply unjust.
If you’re experiencing challenges with ACO shared savings payments, know that you don’t have to face them alone. With the right approach and support, you can advocate for what you’ve rightfully earned.
