Every question, answered.

An Accountable Care Organization (ACO) is a group of doctors and providers who coordinate care for Original Medicare (Fee-for-Service) patients.

Unlike Medicare Advantage, ACOs do not change your patient's coverage, narrow their network, or restrict their providers — they keep traditional Medicare with full provider choice. The ACO earns shared-savings distributions when it lowers total cost of care while maintaining quality. Practices continue billing Medicare FFS as usual; shared savings come on top of normal reimbursement.

The Medicare Shared Savings Program (MSSP) is the largest and most established Medicare ACO program, run by CMS since 2012. Each MSSP ACO has a CMS-assigned spending benchmark for its attributed beneficiaries. If the ACO comes in under that benchmark while hitting quality measures, CMS pays out a share of the savings — which the ACO then distributes to participating physicians based on agreed terms.

Two streams:

• Fee-for-Service revenue stays unchanged. You continue billing Medicare for visits and procedures exactly as you do today.
• Shared savings on top. When the ACO comes in under its CMS benchmark while meeting quality measures, CMS pays out shared savings annually. We distribute those to participating physicians based on your panel's contribution to the savings.

For many practices this represents a 10–25% revenue lift on top of normal Medicare billing, depending on panel size and performance.

No. Practices keep their panels, their workflows, and their clinical decisions. ACOs do not dictate care, restrict referrals, narrow networks, or interfere with practice operations.

What changes is the visibility and support you gain — analytics on your panel, care management for high-needs patients, transitions-of-care alerts, and reporting infrastructure handled for you. How and whether to use those tools is your choice.

There's no individual practice minimum — the requirement applies to the ACO as a whole. CMS requires an MSSP ACO to have at least 5,000 attributed Medicare FFS beneficiaries to participate.

For individual practices joining an existing ACO, even a small panel adds to the total. We have practices in our network with as few as 50 attributed patients and others with several thousand. Each practice's share of distributions scales with their panel contribution.

CMS uses claim-based attribution. A Medicare FFS beneficiary is attributed to the ACO if a participating practice provides the plurality of their primary care services in a given year. CMS also offers voluntary alignment, where patients can elect to be aligned to a provider, which strengthens attribution.

We monitor attribution continuously so you can see exactly which of your patients are attributed and whether any are at risk of being pulled to competing systems.

CMS calculates each ACO's benchmark using historical spending for the attributed beneficiary population, adjusted for regional cost trends through the Accountable Care Prospective Trend (ACPT). The benchmark is rebased periodically, which can compress returns over time for ACOs that aren't actively managing performance.

The math gets complex — risk score normalization, regional adjustments, blend factors — and small changes have large dollar implications. We model your benchmark continuously and help structure operations to preserve as much margin as possible.

MSSP is the long-established Medicare Shared Savings Program. LEAD is the newer track introduced for the 2027 performance year, designed to preserve more upside for ACOs by anchoring the benchmark to a starting year and avoiding the harsh rebasing that erodes MSSP returns over time.

LEAD also includes Enhanced PCC (Primary Care Capitation) payments and admin add-ons that can substantially increase practice revenue — Scenario modeling shows 81–101% revenue increase over FFS for some small practices. We model both and help your ACO decide which fits.

BASIC track is a glide path with five levels (A, B, C, D, E). Levels A and B are one-sided (upside only). Levels C, D, and E introduce progressively more two-sided risk.

Enhanced track has the highest risk and the highest reward — up to 75% shared savings rate with maximum downside risk.

AIP (ACO Investment Pathway) is for new low-revenue ACOs and provides advance payments to support startup operations.

Most new ACOs start in BASIC A/B for the upside-only protection and progress as their operations mature.

In the MSSP ACOs we manage, participating physicians take on no individual downside risk — you do not personally backstop losses. The ACO entity assumes risk where applicable. For ACOs in upside-only BASIC tracks (A and B), there is no downside risk at all.

For ACOs in two-sided risk tracks, CMS requires committed credit before Day 1 — typically $2.5–4M for a $100M benchmark ACO. We handle that financial infrastructure on the ACO side. Physicians share in upside without backing the downside.

The Intensive Primary Care (IPC) High Needs Program is a CMS initiative providing enhanced support and additional per-beneficiary payments for the most complex, highest-need Medicare patients in an ACO's panel.

Patients qualify based on clinical complexity factors — multiple chronic conditions, recent high utilization, ED visits, or functional limitations. The program provides additional resources for intensive care coordination, transitions of care, and home-based support. We identify your IPC-eligible patients and deploy the care team and workflows on your behalf.

Two ways. First, you continue billing Medicare Fee-for-Service exactly as you do today — that revenue is untouched and entirely yours. Second, when the ACO comes in under its CMS budget while hitting quality measures, CMS pays out shared savings annually. We distribute those shared savings to participating physicians transparently, based on your panel's contribution to performance.

You see exactly how every dollar was earned. No black box. No surprise reductions.

• Technology: analytics platform, CCLF data integration, physician-level performance dashboards
• Care management: high-needs programs, IPC, transitions of care, ADT alert response
• Coding infrastructure: RAF/HCC coding workflows and point-of-care support
• Compliance: full 42 CFR Part 425 compliance, MIPS, quality measure tracking, RADV audit support, medical records retrieval
• Strategic advisory: ongoing performance reviews, modeling, optimization

For groups forming a new ACO, we also handle CMS application, governance setup, and network development end-to-end.

Medicare Platform is the operations infrastructure for accountable care. We deliver analytics, attribution monitoring, RAF/HCC coding infrastructure, care management programs, physician-level reporting, and full compliance — as a managed service. Physician groups and ACOs partner with us instead of trying to build all of this internally, which is cost-prohibitive for anyone other than the largest organizations.

Most physicians reach steady-state operations within 90–120 days. The standard rollout is:

• Weeks 1–2: Discovery and benchmarking — we analyze your panel and identify performance opportunities
• Weeks 2–6: Data integration — CCLF feeds activated, EHR connections established, BAA executed
• Weeks 6–12: Platform deployment — your physician dashboard goes live, care management activated
• Ongoing: Quarterly reviews, continuous optimization, annual shared-savings distributions

New ACO formation runs longer — typically 6–9 months from kickoff to CMS approval.

Every engagement begins with a fully executed Business Associate Agreement (BAA). All data transmission and storage is HIPAA-compliant, encrypted at rest and in transit. Data ownership stays with the ACO and the practices — we are a business associate, not the owner.

We maintain documented breach notification protocols, role-based access controls, and our compliance posture meets the standards required by CMS for ACO operations.

Total investment typically ranges from $575K–$600K through revenue generation:

• ACO Development: $75K–$100K at formation — legal entity, governing body, bylaws, CMS application
• Network Development (1st): ~$250K — provider underwriting, agreements, onboarding, data infrastructure
• Network Development (2nd): ~$250K — network completion, technology deployment, clinical launch

For ACOs entering two-sided risk tracks, CMS additionally requires committed credit before Day 1 — typically $2.5–4M for a $100M benchmark ACO.

From kickoff to CMS approval, plan for 6–9 months. CMS opens the MSSP application window once per year, typically in late spring/early summer for the following January 1 start date. Missing the window means waiting a full year. We manage the application end-to-end and pace the formation work to hit the deadline.

An MSSP ACO must be a separately formed legal entity with documented governance: a governing body with at least 75% control by ACO participants, a Medicare beneficiary representative, written bylaws, a compliance officer, conflict-of-interest policies, and detailed agreements with each participating provider.

We handle the legal structure, drafting, and CMS application as part of the formation process — and stand up the ongoing compliance infrastructure to keep the ACO in good standing year after year.

CMS and the OIG have issued specific fraud and abuse waivers that protect ACO participants and their financial arrangements. These waivers cover the Stark Law, the Anti-Kickback Statute, and the Civil Monetary Penalties Law, and apply to:

• ACO pre-participation arrangements
• ACO participation arrangements
• Shared savings distributions
• Compliance with quality measures
• Patient incentives provided through the ACO

Our agreements and operational structure are designed to meet the conditions of these waivers, so participating physicians can engage in coordinated-care arrangements without legal exposure.

42 CFR Part 425 is the federal regulation governing Medicare ACOs. Compliance includes governance structure, beneficiary notification requirements, quality reporting, financial reporting, anti-trust and anti-fraud safeguards, marketing restrictions, beneficiary protections, and ongoing CMS reporting obligations.

We manage the full compliance posture end-to-end — drafting, filing, tracking, and updating — so participating practices don't need internal compliance infrastructure dedicated to ACO operations.

Risk Adjustment Data Validation (RADV) audits are CMS's mechanism to verify that the diagnosis codes used for risk adjustment are supported by the underlying medical record. CMS samples a subset of beneficiaries and requests medical record documentation.

If you're audited, we handle medical records retrieval, organization, and submission on your behalf. Our coding workflows are designed to ensure documentation supports every code submitted, so audits become an administrative event rather than a financial risk.