Variation in Out-of-Network in Medicare ACOs
Effective referral management is an important ACO competency. Referring patients to affiliated ACO clinicians helps ensure clinicians have access to the patient’s most recent clinical information, reduces duplicative or unnecessary services, facilitates timely handoffs across care teams and. Managing care within the ACO provider network has the potential to improve performance in both value-based and traditional fee-for-service contracts. This analysis uses our 100% sample of Medicare claims data to analyze rates of out-of-network utilization for both primary care and specialist services.
Out-of-network utilization varies based on the geographic market and network structure of each ACOs. In order to make reasonable comparisons across similar ACOs we split all 2019 MSSP ACOs into four categories as shown in Exhibit 1.