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March 27, 2018

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Medical Coding News Archives

New Payment Model Qualifies as APM

February 14, 2018:

The Centers for Medicare and Medicaid Services (CMS) is rolling out a new payment model to begin in the fall of this year, called Bundled Payments for Care Improvement Advanced (BPCI Advanced). The new, voluntary model is an expansion of the existing BPCI that bundles just inpatient clinical episodes. It qualifies as an advanced alternative payment model (APM) under the Quality Payment Program (QPP).

CMS is relying on providers to voluntarily explore payment methods that foster care improvement and efficiency. All BPCI Advanced participants would take on some downside financial risk to qualify for incentive payments for services related to 32 types of clinical episodes (29 inpatient and three outpatient). Payments would hinge on meeting seven quality measures efficiently. There will be one risk track and one retrospective bundled payment, and the duration of the clinical episodes will be 90 days. Every six months, CMS will compare fee-for-service expenses for all items and services provided in an episode of care against a target price. If the comparison is favorable, the provider of services will receive a CMS payment, but if expenses exceed the target, the provider will have to repay CMS.

Qualified participants include physician group practices or acute care hospitals who may participate in the model independently as a risk-bearing participant or as an “episode initiator” under an agreement with a risk-bearing “convener” participant.

“Convener” participants are defined as those who consolidate downstream entities (“episode initiators”) to enroll in the model. Convener participants, which may or may not be Medicare providers or suppliers, assume the financial risk under the program. An “episode initiator,” who is enrolled in Medicare, can initiate a clinical episode. Physician group practices may be either a convener or nonconvener. A “nonconvener” participant is also an episode initiator.

The three outpatient clinical episodes that will be part of BPCI Advanced are those related to percutaneous coronary intervention, cardiac defibrillation, and back and neck care except for spinal fusion.

The model will run for just over five years, from October 1, 2018, through December 31, 2023. Applications will be accepted through March 12.

Just as CMS is launching this new initiative, the Comprehensive Primary Care Plus (CPC+) payment model is entering its second year with disappointing new-enrollment figures. Although CMS had hoped that as many as 1,000 new practices would join the nearly 3,000 CPC+ providers that participated in the first year of the program, only 165 new practices enrolled for 2018. The reasons for the shortfall are unclear, though one could be that CPC+, unlike BPC Advanced, does not qualify as an APM under the QPP. The lack of enthusiasm includes payers—CMS drastically reduced its planned expansion of the model to just four markets rather than the original 10 because of payer disinterest.


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