What Is Evicore Healthcare?

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What is eviCore?

Patient Resources Sometimes the tests, treatments, and/or procedures ordered by your healthcare provider must undergo a process called prior authorization (PA). (See how it works below.) PA helps ensure that the healthcare your provider requests is as effective, economical, and appropriate as it should be.

• The care you receive should always be backed by the latest scientific evidence; otherwise, it can be inappropriate and expensive, and lead to other unsafe procedures and treatments.
• EviCore uses evidence-based clinical guidelines to determine whether the care you receive is medically appropriate; if care is deemed inappropriate, they can offer appropriate alternative solutions.

To access eviCore’s clinical guidelines,, About eviCore Your health plan is partnering with eviCore healthcare (eviCore), a medical benefits management company, to ensure you get the best possible care. eviCore’s clinical team includes 400+ physicians and, Their sole job is to protect your health and your wallet by making sure your care aligns with the most up-to-date, evidence-based medical guidelines. How does prior authorization work?

1. You visit your healthcare provider, who then requests a test, treatment, or procedure.
2. The request is sent to eviCore for prior authorization. Although the Web is our preferred channel, phone or fax is also acceptable.
3. are applied to the request to make sure it’s in line with the current science and medical best practices. If the request is approved, the patient receives the care requested by the provider.
4. If more information is needed to make a prior authorization decision, the request is sent to a nurse for further review. If the request is approved, the patient receives the care requested by the provider, If the nurse isn’t able to approve the request based on the available information, the request is sent to a medical director for final review.
5. During the medical director review, the following may occur with the request. (1) The request doesn’t meet the evidence-based clinical guidelines-only a medical director can make the determination that a request doesn’t meet the evidence-based clinical guidelines. If this occurs, the patient is notified, and alternative treatment options may be provided. (2) Ais scheduled. A peer-to-peer review means that the requesting provider meets directly with an eviCore medical director (of similar medical specialty) to review the request more closely. If the patient’s healthcare provider can offer additional information, a decision about the request can be made.

1. If the request from your healthcare provider doesn’t meet the evidence-based guidelines, you’ll receive a letter from eviCore letting you know it wasn’t approved and why it was denied. The “why” will include a reference to the medical guidelines in question, which are completely transparent and available on eviCore’s website for your review. When possible, these letters may include an alternative course of action that would better meet the clinical guidelines. In this situation, we are providing you with some options for potential next steps.
2. If you want an additional review of the initial request, you can ask your healthcare provider to set up a discussion with one of eviCore’s medical directors, who will be from your provider’s specialty. This discussion allows for the exchange of additional clinical information regarding your medical situation without the “red tape” of a formal appeal. Peer-to-peer discussions often result in a more clinically appropriate decision about whether to do a certain test, treatment, and/or procedure. While this discussion must be conducted by your provider, he or she can easily schedule it online at a time that is convenient to them.
3. The letter you receive(d) will also outline how you can formally the request decision through your health plan’s process. The letter will also provide greater detail on the steps and process for the appeal. Unlike the peer-to-peer discussion your provider can engage with, this process can be undertaken by you, the health plan member, but it may take longer and involve more steps.

What is prior authorization? is a process that helps ensure that the test, treatment, and/or procedures your provider requests is as effective, affordable, and as medically appropriate as it should be. The care you receive should always be backed by the latest scientific evidence; that way, we make sure that the care you receive is safe as well as clinically and financially right for you.

For example, imagine that you take your car to an auto repair shop with an oil leak. After some significant testing, the repair shop also identifies that you need new tires and a new engine leaving you with significantly more cost and services than you initially had intended. Who is eviCore? eviCore is a company who works with health plans to help their members, like you, avoid unnecessary care that is costly and potentially unsafe.

We do that by applying the latest evidence-based medical guidelines through a process referred to as prior authorization. eviCore’s clinical team includes 300 physicians and clinical therapists and nearly 800 nurses. Their sole job is to protect your health and your wallet by making sure the care you receive is backed by the latest science.

• These are some of the most common reasons that a test, treatment, and/or procedure might not be approved:
• More clinical information is needed: There are times when eviCore needs to receive more clinical information from your healthcare provider, like medical history or tests you’ve already had, to determine whether the request meets the latest evidence-based medical guidelines.
• More conservative therapy should be tried first: Evidence-based guidelines often point to trying conservative solutions like rest, ice, or elevation first before moving on to more invasive options that involve scans, scopes, and needles.
• A preliminary test is lacking: In some cases, the request of treatment requires that a precursor test – like an ultrasound or x-ray – should always be tried prior to a more complicated procedure like advanced imaging (such as an MRI or a CT scan) or surgery.

What are my options following a denial? Navigating the letter you receive(d) from eviCore: If the request from your healthcare provider doesn’t meet the evidence-based guidelines, you’ll receive a letter from eviCore letting you know it wasn’t approved and why it was denied.

The “why” will include a reference to the medical guidelines in question, which are completely transparent and available on eviCore’s website for your review. When possible, these letters may include an alternative course of action that would better meet the clinical guidelines. In this situation, we are providing you with some options for potential next steps.

Option 1: Peer-to-Peer Discussion If you want an additional review of the initial request, you can ask your healthcare provider to set up a with one of eviCore’s medical directors, who will be from your provider’s specialty. This discussion allows for the exchange of additional clinical information regarding your medical situation without the “red tape” of a formal appeal.

Peer-to-peer discussions often result in a more clinically appropriate decision about whether to do a certain test, treatment, and/or procedure. While this discussion must be conducted by your provider, he or she can easily schedule it online at a time that is convenient to them. Option 2: Formal Appeal The letter you receive(d) will also outline how you can formally the request decision through your health plan’s process.

The letter will also provide greater detail on the steps and process for the appeal. Unlike the peer-to-peer discussion your provider can engage with, this process can be undertaken by you, the health plan member, but it may take longer and involve more steps.

1. What are clinical guidelines? eviCore has a variety of solutions to ensure you get the most appropriate care.
2. Each solution uses evidence-based clinical guidelines to help patients avoid tests, treatments or procedures that research has shown are unnecessary, ineffective, dangerous, or overpriced.
3. EviCore’s evidence-based clinical guidelines are based on information from medical societies such as the American College of Radiology and the American College of Cardiology, as well as the latest peer-reviewed medical journals.

These clinical guidelines are intended to support and enhance sound medical judgement. The guidelines are one of the tools that expert medical professionals who support eviCore as an in-house physician or therapist can use to determine whether the care you receive is medically appropriate; if care is deemed inappropriate, they can offer appropriate alternative solutions.

While evidence-based clinical guidelines are generally developed from large-scale studies and statistics, eviCore provides ready, clear channels, including peer reviews and appeals, by which clinicians can advocate for a patient’s unique circumstances or needs. What is the risk if a patient receives too many medical tests? Some common radiological tests are frequently ordered inappropriately, i.e., without an indication that is supported by scientific evidence.

To help navigate these challenges with a vast selection of diagnostic tools, eviCore provides feedback to requesting physicians with explanations on when a request is appropriate, and when a request may be denied because it’s not the best treatment option for the patient.

• Additional testing because of a false positive test result
• Interference with pacemakers or other internal devices
• Magnetic pull that has the potential to tear out aneurysm clips, piercings, or shrapnel
• Unnecessary surgery
• If performed with contrast:
  • Kidney damage
  • Allergic reaction to contrast
  • Deposit of IV contrast that does not always leave the brain
• Excessive and repeated exposure to radiation.

It is in everyone’s best interest that we limit these potential testing risks when a conservative approach or less invasive test may produce the desired results. IMPORTANT : In the coming days, we will be migrating systems for our eviCore positions. Beginning Friday, December 18th at 5:00pm EST, you won’t be able to apply to eviCore openings.

Is eviCore a Cigna?

EviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for Cigna Healthcare.

What is the other name for eviCore?

CareCore & MedSolutions Rebrands as eviCore healthcare.

What is aim and eviCore?

Checking the status of AIM and eviCore authorization requests on NaviNet ® Open – In certain instances, Independence delegates utilization review activities to entities with expertise in medical management of a certain membership population or type of benefits. Independence has delegated specific review activities to:

AIM Specialty Health ® (AIM), an independent companyCareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent specialty benefit management company

As an important reminder, you may check the status of finalized AIM and eviCore authorization requests through the Authorizations transaction on the NaviNet web portal (NaviNet Open).

Who acquired eviCore?

Express Scripts to Acquire eviCore healthcare; Accelerates Company’s Shift to Patient Benefit Management ST. LOUIS and BLUFFTON, S.C., Oct.10, 2017 /PRNewswire/ – Express Scripts Holding Company (NASDAQ: ) today announced that it has reached an agreement to acquire privately-held eviCore healthcare, the industry leader in evidence-based medical benefit management services, for $3.6 billion,

Combining Express Scripts’ leading pharmacy benefit management offering and eviCore’s highly complementary medical benefits management (MBM) platform will create a uniquely comprehensive patient benefit management solution. Express Scripts is acquiring eviCore from current investors including General Atlantic, TA Associates, and Ridgemont Equity Partners.

The transaction is subject to customary regulatory approvals and closing conditions, and is expected to close in the fourth quarter of 2017. “The rising cost of healthcare is one of the most important issues facing Americans today,” said Tim Wentworth, President and CEO of Express Scripts.

1. Together with eviCore, Express Scripts will be an even more powerful partner in managing costs for patients and payers, bringing us closer to our goal of becoming the nation’s leading patient benefit manager.
2. By further strengthening our independent model and creating numerous opportunities for growth, the acquisition of eviCore will deliver value for our clients, patients, providers, and shareholders.” “The greatest opportunity to improve healthcare is by reducing wasteful spend and overutilization while delivering quality outcomes,” said John Arlotta, Chairman and CEO of eviCore.

“Together, eviCore and Express Scripts will be uniquely positioned to tackle these problems. We are proud of what we have accomplished over 25 years of serving patients and clients and we are excited about our future with Express Scripts.” eviCore, which manages medical benefits for 100 million people, offers a broad range of integrated MBM solutions that drive significant and immediate cost reductions, and improved quality care outcomes.

1. EviCore has leading positions managing benefits in categories including radiology, cardiology, musculoskeletal disorders, post-acute care and medical oncology – all important therapeutic areas that are in need of greater cost management.
2. EviCore contracts with health plans and commercial clients to better ensure appropriate use of healthcare services.

eviCore has approximately 4,000 employees and will operate as a standalone business unit within Express Scripts. The acquisition of eviCore will give Express Scripts an attractive entry point into a growing market. Today, pharmacy is an industry with approximately $400 billion in annual spend.

Healthcare spend represents nearly $3.4 trillion, Medical benefit management is a large and growing market with more than $300 billion spent annually in the areas eviCore manages today. Establishing a cornerstone platform in this market will enable Express Scripts to build a uniquely comprehensive suite of solutions, with significant opportunities for cross-selling to both client bases.

The combination of Express Scripts’ leading independent PBM model and eviCore’s industry-leading medical cost containment capabilities across an expanded client base will create an even more powerful partner for our clients, fully aligned with the interests of patients and payers.

• Excluding transaction related expenses and amortization of intangibles, Express Scripts expects the acquisition to be accretive to adjusted diluted earnings per share in its first full year of operation.
• The company will provide additional information pertaining to the proposed acquisition of eviCore on its upcoming earnings call scheduled for October 25, 2017,
• Advisors

Express Scripts’ financial advisors on this acquisition are Lazard and TripleTree, LLC. Its legal advisor is Skadden, Arps, Slate, Meagher & Flom, LLP. eviCore’s financial advisors are J.P. Morgan Securities LLC and Morgan Stanley & Co. LLC. Its legal advisor is Paul, Weiss, Rifkind, Wharton & Garrison, LLP.

About Express Scripts Express Scripts puts medicine within reach of tens of millions of people by aligning with plan sponsors, taking bold action and delivering patient-centered care to make better health more affordable and accessible. Headquartered in St. Louis, Express Scripts provides integrated pharmacy benefit management services, including network-pharmacy claims processing, home delivery pharmacy care, specialty pharmacy care, specialty benefit management, benefit-design consultation, drug utilization review, formulary management, and medical and drug data analysis services.

Express Scripts also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services. For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter. About eviCore eviCore offers proven, diversified medical benefits management solutions that help clients reduce costs while increasing quality of care for their members.

The company provides these solutions to managed care organizations and risk-bearing provider organizations serving commercial, Medicare, and Medicaid populations. Powered by a team of specialized medical professional resources, extensive evidence-based guidelines, and advanced technologies, eviCore supports clients by ensuring the right evidence-based care is delivered at the right time to the right patient at the right site of care.

Flexible medical benefits management solutions are offered in: Radiology; Cardiology; Musculoskeletal; Medical Oncology; Radiation Therapy; Specialty Drug Management; Sleep; Lab Management; and Post-Acute Care. eviCore is proud to help 100 million members receive higher quality, lower cost healthcare.

• For more information, please visit evicore.com.
• Safe Harbor Statement This press release contains forward-looking statements, including, but not limited to, business outlook and our statements related to the Company’s plans, objectives, expectations (financial and otherwise) or intentions.
• Actual results may differ materially from those projected or suggested in any forward-looking statements.

Factors that may impact these forward-looking statements can be found in Management’s Discussion and Analysis of Financial Condition and Results of Operations and Item 1A – “Risk Factors” in the Company’s Annual Report on Form 10-K filed with the SEC on February 14, 2017 and the Company’s Quarterly Report on Form 10-Q filed with the SEC on July 25, 2017.

1. Media Contact: Brian Henry 314-684-6438
4. Investor Contact: Ben Bier 314-810-3115
7. SOURCE Express Scripts

How long has eviCore been around?

Frequently Asked Questions eviCore is the recognized industry leader in medical benefits management, with more than 25 years of experience covering 100 million lives. Our technological capabilities, coupled with our forward-thinking approach, afford us opportunities to be more innovative—creating new ways to solve problems in utilization, cost, quality outcomes, and cost containment, especially as the market adopts value-based care.

• We have the best benchmark data, the most thorough understanding of payer markets, and the deepest clinical expertise with more than 1,000 full-time clinicians.
• We maintain the industry’s most comprehensive, well documented, and up-to-date clinical guidelines.
• With in-depth clinical expertise, we are a provider-driven organization with many in-house specialists who understand the concerns of your provider community and are sensitive to them.

IMPORTANT : In the coming days, we will be migrating systems for our eviCore positions. Beginning Friday, December 18th at 5:00pm EST, you won’t be able to apply to eviCore openings. We’re still hiring for other open positions so continue your job search at : Frequently Asked Questions

What does eviCore handle?

Frequently Asked Questions eviCore works with health plans to help their members like you avoid unnecessary care that is costly and potentially unsafe. We do that by applying the latest evidence-based medical guidelines through a process sometimes referred to as prior authorization.

• EviCore’s team has 300 physicians and therapists and nearly 800 nurses with experience in multiple specialties whose sole job is to protect your health and your wallet by making sure you get care that is backed by the latest science.
• IMPORTANT : In the coming days, we will be migrating systems for our eviCore positions.

Beginning Friday, December 18th at 5:00pm EST, you won’t be able to apply to eviCore openings. We’re still hiring for other open positions so continue your job search at : Frequently Asked Questions

Who is the CEO of eviCore?

John Arlotta serves as the CEO / President of eviCore healthcare.

Is Cigna in New York?

Cigna’s group of highly qualified doctors who meet our standards of care is one of the largest in the New York and New Jersey area with over 30,000 personal doctors and over 115,000 specialists.

What are synonyms for EHR?

EMR, EHR, or PHR: What’s In A Name? Consider for a moment these three terms: electronic medical record (EMR), electronic health record (EHR), and personal health record (PHR). If you’re familiar with these terms then you have, at some point, likely become familiar with the fact that they are often used interchangeably.

• Why is this? They probably don’t mean the same things, right? The reason for the confusion can be traced back to how the terms are differentiated.
• Generally, when defining something one looks for what is essential about that thing and works up from there to create a definition that will allow it to be easily distinguished from other, similar things.

These three terms however, are not defined by what they essentially are, but rather how they (the records) are used, shared and controlled. And this seems to lend itself to the terms being used imprecisely more often than not. First, let’s generally consider what the three terms are and how they are alike.

The three have much in common: they are all types of records ( i.e., collections or repositories of data), and these records broadly contain health-related information. It’s probably safe to assume that both electronic health records and electronic medical records contain some health-related information that is personal in nature, so this would mean there is some overlap with personal health records.

Another area of overlap would be that two of the three, electronic health records and electronic medical records, are “electronic,” although any further similarities quickly come to an end since one has the designation “health” attached to it, and the other “medical.” Similarly, personal health records and electronic health records are both health (not medical) records, but one is “personal,” and one “electronic,” perhaps indicating the importance of the nature of the record rather than the medium of storage.

The confusion grows worse if one assumes, quite reasonably, that personal health records can and do come in electronic form. And lastly, both EHR and EMR are often used to refer to the systems of storage (software, databases and so on) that house such records. With all this, it’s easy to see why things have become so muddled.

Definitions based on how the records are used, shared, and controlled have been introduced and are slowly gaining adoption. In 2008, the Office of the National Coordinator of Health Information Technology (ONHIT) commissioned their partner organization, the National Alliance for Health Information Technology (NAHIT) to come up with proposed definitions to help codify health information technology terms.

What are the values of eviCore?

Our Core Values We strive for honesty, transparency, and authenticity in all our actions and interactions. We anticipate and respond to changes in technology, markets, and work environments. We consider and respect the unique needs and interests of each individual.

What is the motto of eviCore?

About eviCore ABOUT EVICORE: Empowering the Improvement of Care” /> Specifically designed with the size and scale to address the complexity of today’s and tomorrow’s healthcare system, eviCore is a company committed to advancing healthcare management through intelligent care – and enabling better outcomes for patients, providers, and health plans. Ours is an evidence-based approach that leverages our exceptional capabilities, powerful analytics, and acute sensitivity to the challenges and needs of everyone involved across the healthcare continuum. By applying proven talent and leading-edge technology, we harness healthcare’s evolving demand and inherent change to realize healthcare innovation and deliver improved results and a positive experience for everyone. eviCore empowers the improvement of care by connecting patients, providers, and health plans with intelligent, evidence-based solutions to enable better outcomes. eviCore empowers the improvement of care for patients by promoting appropriate, evidence-based decision making and quality measurement. We help strengthen the patients/provider relationship and help educate patients and providers. eviCore empowers the improvement of care for providers by facilitating evidence-based decision making and quality reporting while reducing administrative burdens and costs. We promote transparent, shared decision making and ongoing education for new products and standards in the marketplace. eviCore empowers the improvement of care for health plans by delivering proven, diversified medical benefits management solutions that improve the quality of care for their members while reducing waste and abuse. Our proprietary analytics highlight areas of over-utilization and unnecessary spend, as well as pinpoint areas of the greatest opportunity to improve care and increase savings.

What does AIM stand for healthcare?

Accountable Care Organization Investment Model (AIM) **This fact sheet was updated on 03/24/2017** Overview Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to provide coordinated, high-quality care to their Medicare patients to help them deliver better care at lower cost.

The goal of coordinated care is to ensure that patients, especially people with chronic conditions, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. ACOs represent one part of a comprehensive series of initiatives in the Affordable Care Act that are designed to lower costs and improve care.

When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. Medicare currently offers several ACO initiatives:

• Medicare Shared Savings Program (Shared Savings Program)
• Next Generation ACO Model (NGACO)
• ACO Investment Model (AIM)
• Comprehensive End Stage Renal Disease (ESRD) Care Initiative

This fact sheet provides a general description of AIM, an ACO model being offered to support Shared Savings Program ACOs. The Shared Savings Program provides financial incentives for ACOs to lower growth in health care costs while meeting performance standards on quality of care and putting Medicare beneficiaries first.

Summary of the ACO Investment Model AIM is an initiative developed by the Center for Medicare and Medicaid Innovation (Innovation Center) designed for organizations participating as ACOs in the Shared Savings Program. AIM is a model of pre-paid shared savings that builds on the experience with the Advance Payment ACO Model to encourage new ACOs to form in rural and underserved areas and current Shared Savings Program ACOs to transition to arrangements with greater financial risk.

The model is expected to provide a total of $96 million in upfront and ongoing investments to AIM participants. AIM was available to: 1. New Shared Savings Program ACOs that joined in 2015 or 2016. AIM seeks to encourage uptake of coordinated, accountable care in rural geographies and areas where there has been little ACO activity, by offering pre-payment of shared savings in both upfront and ongoing per beneficiary per month payments.

1. CMS believes that encouraging participation in areas of low ACO penetration may spur new markets to focus on improving care outcomes for Medicare beneficiaries.2.
2. ACOs that joined the Shared Savings Program starting in April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014.
3. Here, AIM helps ACOs to succeed in the Shared Savings Program and encourages progression to higher levels of financial risk, ultimately improving care for beneficiaries and generating Medicare savings.

Participants AIM consists of 45 participating ACOs across 38 states, including 2 ACOs selected for a 2015 AIM start and 43 ACOs selected for a 2016 AIM start. Both ACOs selected for a 2015 AIM start began participating in the Shared Savings Program in 2013.

• Of the 43 ACOs selected for a 2016 AIM start, 2 are 2014 Shared Savings Program starters, 5 are 2015 Shared Savings Program starters and 36 are 2016 Shared Savings Program starters.
• Number of Beneficiaries : As of January 2017, AIM participants serve a combined total of over 487,000 beneficiaries nationwide; an increase of 53,000 beneficiaries from January 2016.

ACO Infrastructure : 27 ACOs report having a Critical Access Hospital (CAH) or Inpatient Prospective Payment System (IPPS) hospital with fewer than 100 beds as part of their ACO structure. Geographic Coverage of AIM Participants :

38 States Represented by AIM Participants
Northeast	South	Midwest	West
Maine	Alabama	Illinois	Arizona
Maryland	Florida	Indiana	California
New Hampshire	Georgia	Iowa	Colorado
Pennsylvania	Kentucky	Kansas	Idaho
Vermont	Mississippi	Michigan	Montana
	North Carolina	Minnesota	Nevada
	Oklahoma	Missouri	New Mexico
	South Carolina	Nebraska	Oregon
	Tennessee	North Dakota	Washington
	Texas	Ohio	Wyoming
	West Virginia	South Dakota
		Wisconsin

List of AIM ACOs :

• Access Care Oklahoma, LLC
• Affiliated ACO, LLC
• Akira Health of Los Angeles Inc
• Akira Health, Inc
• Aledade Kansas ACO, LLC
• Aledade Mississippi ACO, LLC
• Aledade West Virginia ACO, LLC
• Alliance ACO, LLC
• AmpliPHY of Kentucky ACO LLC
• AmpliPHY of Texas ACO LLC
• Beacon Rural Health
• California ACO
• Carolina Medical Home Network Accountable Care Organization LLC
• Citrus County ACO, LLC
• Deep South Regional ACO
• Great Plains Care Organization
• Greater Michigan Rural ACO
• Heartland Physicians ACO, Inc.
• High Sierras-Northern Plains ACO
• Illinois Rural ACO
• Illinois Rural Community Care Organization LLC
• Indiana Rural ACO
• Iowa Rural ACO
• Kentucky Primary Care Alliance
• Magnolia-Evergreen ACO
• Minnesota Rural ACO
• MissouriHealth+
• Mountain Prairie ACO
• Mountain West ACO
• New Hampshire Rural ACO
• North Mississippi Connected Care Alliance
• Ohio River Basin ACO
• Oregon – Indiana ACO
• Prairie Hills Care Organization
• PremierMD ACO, LLC
• Reid ACO
• Rocky Mountain Accountable Care Organization, LLC
• San Juan Accountable Care Organization, LLC
• Southern Michigan Rural ACO
• Suburban Health ACO 2
• Sunshine ACO LLC
• Tar River Health Alliance, LLC
• Texas Rural ACO
• The Premier HealthCare Network LLC
• Winding River ACO

Rural Location AIM encourages ACO development in rural and underserved areas. Of the 45 participants, 36 have at least 65 percent of their delivery sites in rural areas. Quality of Care : Nine of the current AIM participants also participated in Performance Year 2015 of the Shared Savings Program.

All nine ACOs met the required quality performance standards for Performance Year 2015. Financial Performance : Of the nine current AIM participants who participated in Performance Year 2015 of the Shared Savings Program, two achieved shared savings. These two ACOs generated $15,978,282 in total savings and earned $7,367,396 in shared savings.

Structure of Payments Test 1 (Shared Savings Program Start Date in 2015 or 2016) Under AIM, ACOs that began participating in the Shared Savings Program in 2015 or 2016 receive three types of payments:

• An upfront, fixed payment : Each ACO receives a fixed payment;
• An upfront, variable payment : Each ACO receives a payment based on the number of its assigned beneficiaries; and
• A monthly payment of varying amount depending on the size of the ACO : Each ACO receives a monthly payment based on the number of its assigned beneficiaries.

The structure of these payments addresses both the fixed and variable costs associated with forming an ACO. Test 2 ACOs (Shared Savings Program Start Date of April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014) Under AIM, ACOs that began participating in the Shared Savings Program on April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014 receive two types of payments:

• An upfront, variable payment : Each ACO receives a payment based on the number of its assigned beneficiaries; and
• A monthly payment of varying amount depending on the size of the ACO : Each ACO receives a monthly payment based on the number of its assigned beneficiaries.

The structure of these payments addresses both the fixed and variable costs associated with making ongoing investments to improve care coordination for existing ACOs. Recovery of AIM Payments Test 1 ACOs (Shared Savings Program Start Date in 2015 or 2016) For ACOs that began participating in the Shared Savings Program in 2015 or 2016, CMS will recover payments from earned shared savings for the first two agreement periods that the participant remains in the Shared Savings Program.

• CMS will recover all pre-payments up to the total shared savings earned by the ACO, but will not pursue amounts in excess of the earned shared savings.
• Should an ACO not earn sufficient shared savings in the first Shared Savings Program agreement period to fully repay pre-payments, and should the ACO not enter a second Shared Savings Program agreement period, then CMS will not pursue full recovery of remaining pre-payments from that ACO.

CMS will pursue full recovery of pre-paid shared savings from any ACO that does not complete its initial Shared Savings Program agreement period or the full term of the AIM agreement. Test 2 ACOs (Shared Savings Program Start Date of April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014) For ACOs that began participating in the Shared Savings Program prior to 2015, CMS will also recover payments from earned shared savings for the first two agreement periods that the participant remains in the Shared Savings Program.

CMS will recover all pre-payments up to the total shared savings earned by the ACO, but will not pursue amounts in excess of the earned shared savings during the first two Shared Savings Program agreement periods. If the ACO does not earn sufficient savings to repay the AIM pre-paid shared savings during their second Shared Savings Program agreement period, the ACO will be required to repay the outstanding balance directly.

CMS will also pursue full recovery of pre-paid shared savings if the ACO terminates before the end of their second Shared Savings Program agreement period. Eligibility/Selection AIM helps provide support to organizations whose ability to invest in infrastructure and redesigned care processes is improved with additional access to capital.

1. The ACO must be accepted into and participate in the Shared Savings Program. The ACO’s first performance period in the Shared Savings Program must have started in April 1, 2012, July 1, 2012, January 1, 2013, January 1, 2014, January 1, 2015, or January 1, 2016.
2. The ACO has completely and accurately reported quality measures to the Shared Savings Program in the most recent performance year, if the ACO started in the Shared Savings Program in April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014.
3. The ACO has a beneficiary assignment of 10,000 or fewer beneficiaries for the most recent quarter, as determined in accordance with the Shared Savings Program regulations, excluding ACOs that start in 2015 or 2016. An ACO that began participating in 2015 or 2016 must have a beneficiary assignment of 10,000 or fewer, unless they are serving a rural area.
4. The ACO does not include a hospital as an ACO participant or an ACO provider/supplier (as defined by the Shared Savings Program regulations), unless the hospital is a critical access hospital (CAH) or inpatient prospective payment system (IPPS) hospital with 100 or fewer beds.
5. The ACO is not owned or operated in whole or in part by a health plan.
6. The ACO did not participate in the Advance Payment ACO Model.

During the selection process, AIM targeted new ACOs serving rural areas and areas of low ACO penetration and existing ACOs committed to moving to higher risk tracks. CMS gave preference to ACOs that provide high quality of care, ACOs that achieved their financial benchmark, ACOs that demonstrated exceptional financial need, and those that submitted compelling proposals for how they will invest both their own funds and CMS funds.

Currently, there are no plans to open another application cycle and add more ACOs to this model. Additional Resources The Innovation Center The CMS Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for Medicare, Medicaid and Children’s Health Insurance Program beneficiaries.

Working in concert with the Shared Savings Program, the CMS Innovation Center is testing a number of ACO models and has sponsored learning activities that help providers form ACOs and improve their results. More information on all of these initiatives is available on the CMS Innovation Center website at http://innovation.cms.gov,

More information about the AIM is available on the Innovation Center website at http://innovation.cms.gov/initiatives/ACO-Investment-Model/, Any questions about the program can be directed to [email protected], For information about the Shared Savings Program, please see: www.cms.hhs.gov/sharedsavingsprogram/,

For Medicare Shared Savings Program ACO Performance Year 2015 results, please visit: https://data.cms.gov/ACO/Medicare-Shared-Savings-Program-Accountable-Care-O/x8va-z7cu, ###

What is the largest health information exchange infrastructure in the United States?

Answer 3: The eHealth Exchange is a continually growing health information exchange network for securely sharing clinical information over the Internet nationwide. It is the largest HIE infrastructure in the United States (U.S.).

Does MVP use eviCore?

MVP’s partner, eviCore Healthcare, manages our members’ use of radiology services to improve the quality, affordability and safety of the services you receive.

Who is the CEO of eviCore?

John Arlotta serves as the CEO / President of eviCore healthcare.

What is the phone number for eviCore PA?

Who do I contact if I need help? – A chat feature is available on select pages of the website from 7a.m. to 8 p.m., ET, Monday – Friday. You can also email [email protected] or call 800-646-0418, option 2.