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Specialists Can Get Caught in ACO Web of "Primary Care" and Exclusivity

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Specialists participating in accountable care organizations or treating ACO patients may want to reexamine their contracts, as exclusivity provisions of Medicare accountable care organization regulations may prevent specialists from participating in more than one ACO, according to an American Medical News report.

The definition of primary care under Medicare ACOs is very broad, according to the report. Some services provided by specialists, such as evaluation and management services, can fall under the definition of primary care.

Therefore, a specialist who provides an E&M service that falls under those codes to a Medicare patient who has not seen a primary care physician in a certain time frame could have that patient assigned to him or her, and make his or her group physician practice exclusive to that patient's ACO.

Specialists who wish to participate in more than one ACO must be careful to avoid triggering exclusivity to a Medicare ACO. According to the report, specialists can do this by encouraging their patients to see a primary care physician regularly, along with other options, detailed in the report.

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