West Florida 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

Why OIG Did This Review

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 (Quality measure: A standardized method of assessing the quality of care furnished by ACOs. The overall quality performance score is a value that is based on reported data on quality measures and is used to calculate the shared savings payments.) . 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.

Our objective was to determine whether West Florida ACO, LLC (West Florida) complied with applicable Federal requirements when reporting data on quality measures through the CMS web portal.

How OIG Did This Review

We limited our review to West Florida's data on nine quality measures reported through the CMS web portal for PY 2016. We reviewed a stratified random sample of 240 beneficiary-measures.

What OIG Found

For 227 of the 240 sampled beneficiary-measures, West Florida complied with applicable Federal requirements by reporting complete and accurate data on quality measures through the CMS web portal. However, for the remaining 13 sampled beneficiary-measures, West Florida did not comply with requirements. Specifically, the medical records did not support that the beneficiaries (1) should have been either included in or removed from the measure population (Measure population: Beneficiaries (from the sample that CMS provided) for whom CMS measured the quality of care furnished by the ACO through the use of quality measures.) based on the exclusion criteria (Exclusion criteria: A medical condition or a situation that would require removal of a beneficiary from a measure population before reporting whether the conditions of a quality measure were satisfied for a beneficiary (e.g., having an active diagnosis of depression that would require removal of a beneficiary from the measure population for depression screening).) or (2) satisfied the conditions of the quality measures (Conditions of a quality measure: Required outcomes or processes (e.g., screening for future fall risk) for beneficiaries who were included in a measure population.) . Further, the medical records did not support the reported measurement values (Measurement values: Specific values (e.g., a beneficiary's blood pressure reading on a given date) used to determine whether certain conditions were satisfied for a beneficiary. ) or the reported "Patient Reason" exception (Exception reason: A reason that would allow removal of a beneficiary from a measure population if the conditions of a quality measure were not satisfied, e.g., the "Patient Reason" exception (refusal to participate in a required screening).) . Instead, the records supported (1) different measurement values that would have still satisfied the conditions of the quality measure or (2) a "Medical Reason" exception (Exception reason: A reason that would allow removal of a beneficiary from a measure population if the conditions of a quality measure were not satisfied, e.g., the "Medical Reason" exception (low functional capacity).) that would have still removed the beneficiary from the measure population.

These reporting deficiencies, which did not affect West Florida's overall quality performance score, occurred because according to West Florida officials, the ACO participant staff (1) made clerical errors when entering the data and (2) presumed that the beneficiaries did not have an active diagnosis of depression and did not realize that the beneficiaries should have been removed for meeting the exclusion criteria for the depression screening measure. In addition, according to these officials, physicians find it difficult to distinguish between the two exception reasons and, based on a physician's interpretation, either the "Patient Reason" exception or the "Medical Reason" exception may apply.

What OIG Recommends and West Florida Comments

We recommend that West Florida (1) ensure that it accurately reports all data on quality measures through the CMS web portal and (2) clarify with CMS its understanding of the exclusion criteria for a beneficiary to be removed from the measure population and the difference between the "Patient Reason" exception and the "Medical Reason" exception.

West Florida concurred with our findings and described actions that it planned to take to address our recommendations.