Author: Daniela Bolivar
Senior Consultant


Author: Kelly Conroy


(303) 801-0111


Do you want to start an Accountable Care Organization but don’t know where to start or how to financially support the start?

Contact Pinnacle for help with applying to the Advance Investment Payments (AIP).  Centers for Medicare and Medicaid Services (CMS) is proposing to make AIPs available to certain ACOs participating in MSSP beginning on January 1, 2024.  Participants who are accepted will receive an upfront payment of $250,000 for infrastructure and set-up. Participants will also receive a Per Member Per Month (PMPM) payment for care coordination and other value-based care initiatives.

The eligibility requirements include:

  • Must apply and be eligible to participate in the MSSP basic track glidepath (under any level);
  • Must apply to receive AIPs in conjunction with the MSSP application; and,
  • New ACOs (not renewing or re-entering), designated as low revenue, and designated as inexperienced with performance-based risk.

Summary of Changes in Proposed 2023 Medicare Physician Fee Schedule that Affect ACOs

On July 7, 2022, CMS issued a proposed rule for Calendar Year (CY) 2023 Physician Fee Schedule. Some of the proposed changes directly impacts the Medicare Shared Savings Program (MSSP).

These proposed changes are part of CMS’ larger strategy to improve the following:

  1. Alignment
  2. Growth
  3. Equity

The 60-day comment period closes on September 6, 2022. Comments can be submitted at: (in commenting, please refer to file code CMS-1770-P).

The following is Pinnacle’s summary of the proposed CY2023 Physician Fee Schedule:

Payment, E/M Updates & Attribution Updates

  • Approximately a negative 4.5% adjustment due to the conversion factor needing to be budget neutral. The plan is to drop it from $34.61 to $33.08.
  • Update code list to include new prolonged service and chronic pain management codes.
    • Prolonged visit codes to resume being suspended after pandemic.
  • Capture newly-enrolled CCNs for all FQHCs, RHCs, CAHs, and ETA hospitals under an ACO Participant TIN at the start and periodically throughout the performance year.

MSSP Proposed Changes

  • Glidepath to Risk – Easing the transition to downside risk by allowing longer time in upside only arrangements
    • If an ACO is inexperienced with risk, they can participate in up to 7 years of upside only; if an ACO is inexperienced with risk AND low revenue, they can participate in upside only for 12 years
      • Starting for ACOs applying for performance year 2024
    • ACOs already in the BASIC glide path under Levels A or B will have the option to continue their current level for the remainder of the agreement (as of PY2023)
    • Remove the limitation on the number of agreement periods an ACO can participate in Level E of BASIC
    • Enhanced Track will be optional
  • Financial Methodology & Benchmark Changes
    • All of CMS’ proposed benchmarking changes will be effective for new agreements starting in performance year 2024
    • Adding a prospective growth factor (based on the USPCC/ACPT) into a new three-way trend
      • Trend (from BY3 to PY) will be calculated as 1/3 ACPT (Accountable Care Prospective Trend), 2/3 existing national-regional blended trend
      • ACPT will be set for the ACO’s entire 5-year agreement period near the start of the agreement period and remain unchanged for the duration of the agreement period
      • Does not fix, but simply minimizes the “rural glitch”
    • Accounting for Prior Savings Adjustments
      • CMS proposes to reinstitute a policy where an ACO’s generated savings in previous agreements are accounted for when rebasing benchmarks – this includes ALL savings generated, not just those that exceed the MSR
      • Reduce cap on downward adjustment from current 5% of national costs to 1.5% of national costs
      • Gradually decrease negative regional adjustment amount as an ACO’s proportion of dual eligible beneficiaries or HCC risk score increases
    • Risk Adjustment Changes
      • Update 3% risk adjustment cap so that it is applied relative to the demographic risk score growth – similar to the ACO REACH methodology starting in 2024
    • Calculate the Regional Adjustment for ACOs using Prospective Assignment
      • CMS proposed to calculate regional spending using an off-set assignment window that matches that of ACOs under prospective assignment
        • Not proposing changed to national factors in financial calculations
      • Update Assignment Methodology for Regional Costs
        • Regional costs used in benchmark methodology would be identified based on the ACO’s assignment methodology (prospective/retrospective). Currently all regional costs are identified using retrospective attribution
      • Increased Opportunities for Low Revenue ACOs
        • Low revenue ACOs in the BASIC track can share in savings at half of the standard shared savings rate if they generate savings under the MSR and meet the quality standard
          • Maximum savings rate of 20% instead of 40% under Levels A and B
          • Maximum savings rate of 25% instead of 50% under Levels C, D, and E
        • Advance Investment Payments (AIP)
          • Modeled after the ACO Investment Model (AIM)
          • Available to certain ACOs beginning performance year 2024
            • Not renewing or re-entering ACOs
            • Designated as low revenue
            • Designated as inexperienced with performance-based risk
          • AIPs include two types of payments:
            • One-time upfront payment of $250,000
            • 8 quarterly payments calculated per beneficiary (capped at $10,000) paid over 2 years
          • Administrative Burden Reduction
            • Streamline 3-Day SNF Waiver
            • Remove marketing material approval requirement
            • Notify beneficiaries once an agreement period vs. annually
              • New follow up communication proposed

QPP Proposed Changes

  • Remove all or nothing approach in favor of a sliding scale adjustment to shared savings rates
  • New SDOH measures (2)
    • Extension of incentives in place for reporting eCQMs through performance year 2024
    • New bonus opportunity for ACOs reporting cCQMs/MIPS CQM and serving a large proportion of underserved communities
  • Advanced APM Bonus
    • Performance year 2022 is the final year for A-APMs to earn a 5% bonus (paid in 2024)
    • CMS is seeking public comments through an RFI in the proposed rule asking stakeholders about their organization’s plans for future participation in Advanced APMs vs. MIPS

For more information, please contact Kelly Conroy at 561-385-7566 or, or Daniela Bolivar at 561-445-8303 or

Additional Resources