ACO Financial Arrangements Sample Clauses

The ACO Financial Arrangements clause defines how financial transactions and responsibilities are managed within an Accountable Care Organization (ACO) agreement. It typically outlines the methods for distributing shared savings, handling losses, and allocating costs among participating providers or entities. For example, it may specify how payments from payers are divided or how financial risk is shared if expenditures exceed targets. The core function of this clause is to ensure transparency and fairness in financial dealings, thereby reducing disputes and aligning incentives among ACO participants.
ACO Financial Arrangements. A. The ACO shall not condition a Participant Provider’s or Preferred Provider’s participation in the Model, directly or indirectly, on referrals of items or services provided to Beneficiaries who are not aligned to the ACO. B. The ACO shall not require, and shall ensure that its Participant Providers and Preferred Providers do not require, that REACH Beneficiaries be referred only to Participant Providers or Preferred Providers or to any other provider or supplier. This prohibition shall not apply to referrals made by employees or contractors who are operating within the scope of their employment or contractual arrangement with the employer or contracting entity, provided that the employees and contractors remain free to make referrals without restriction or limitation if a REACH Beneficiary expresses a preference for a different provider or supplier, or the referral is not in the REACH Beneficiary's best medical interests in the judgment of the referring party. C. The ACO shall not condition the eligibility of an individual or entity to be a Participant Provider or Preferred Provider on the individual’s or entity’s offer or payment of cash or other remuneration to the ACO or any other individual or entity. D. The ACO shall ensure that no party to an ACO financial arrangement gives or receives remuneration in return for, or to induce or reward, any Federal health care program referrals or business generated outside of the Model, and the compensation does not induce either party or other providers or suppliers to furnish medically unnecessary items or services, or to reduce or limit Medically Necessary items or services to any Beneficiary. E. The ACO shall not take, and shall ensure that its Participant Providers and Preferred Providers do not take, any action to limit the ability of a Participant Provider or Preferred Provider to make decisions in the best interests of a Beneficiary, including the selection of devices, supplies and treatments used in the care of the Beneficiary. F. The ACO shall notify CMS within 15 Days after becoming aware that the ACO, a Participant Provider, or a Preferred Provider is under investigation or has been sanctioned by the government or any licensing authority (including, without limitation, the imposition of program exclusion, debarment, civil monetary penalties, corrective action plans, and revocation of Medicare billing privileges). If the ACO, a Participant Provider, or a Preferred Provider is under investigation or has ...
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