Also conducts true ups to prior period reconciliation

This preview shows page 5 - 7 out of 16 pages.

also conducts “true-ups” to prior period reconciliation results to reflect claims that were not included in the initial reconciliation. CMS performs true-ups for three quarters beyond the initial reconciliation so that quarterly results are not finalized for an additional nine months. CJR will have annual reconciliations, but the process will be generally similar to BPCI. If Medicare beneficiaries are cared for by a BPCI provider or CJR hospital and are also attributed to a MSSP or Pioneer Accountable Care Organization (ACO), the bundled payment provider will be credited with gains or losses for the bundled services and the amounts will be removed from the ACO settlements. If bundled payment providers are part of an MSSP or Pioneer ACO and the ACO earns positive shared savings payment, CMS will recapture any portion of the 2 percent bundled payment discount paid to the ACO as shared savings from the BPCI or CJR provider. Exhibit 3: CJR Composite Quality Score Development Percentile Complications HCAHPS Points Points ≥ 90th 10.00 8.00 ≥ 30th to 5.50 - 9.25 4.40 - 7.40 < 90th < 30th 0.00 0.00 Composite Quality Quality Category Score < 4.0 Below Acceptable ≥ 4.0 to < 6.0 Acceptable ≥ 6.0 to ≤ 13.2 Good > 13.2 Excellent Data PRO Submitted? Measure Points Yes 2.00 No 0.00 } +
6 Exhibit 4: Illustration of BPCI Reconciliation Hospital-specific Target Price 2012 Target Price for Performance Period Reconciliation Gain or Loss Adjusted Actual Performance Update Factor: Actual change in spending by DRG bundle from national data. Wage Index: Apply year to year change. Adjusted for: - Risk tracks - Geographic smoothing - Stop loss Reconcile Quarterly or Annually Post-episode monitoring Under BPCI and CJR, CMS monitors post-episode spending for 30 days to identify any systematic increase in post-episode spending. The monitoring is intended to ensure bundling participants do not shift services out of the episode time period to reduce episode spending. If CMS determines that post-episode spending is systematically higher than it was during the baseline period, bundlers must return excess spending to Medicare. Program waivers Certain waivers of Medicare requirements can help participants in bundling programs implement care redesign more effectively. Under BPCI, participants must provide information about how they plan to modify services or financial arrangements in an implementation protocol (IP) submitted to CMS. Three-day hospital stay waiver for coverage of SNF services. Medicare does not cover care in a SNF unless it is preceded by a three-day acute care hospital stay. Model 2 BPCI participants may apply for a waiver of this provision so that SNF-qualifying hospital admissions may be shorter than three days. As a condition of the waiver, participants must prospectively identify partner SNFs, and the majority of these must be rated three stars or higher under the Nursing Home Compare five star rating system.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture