Answer: CMS is currently limited in its ability to answer the many questions it has received about earnings sharing. CMS called for the abandonment of fraud and abuse for BPCI Advanced; If granted, CMS expects the waiver declarations to take effect at the beginning of the model`s performance period on October 1, 2018. Waiver declarations may be reviewed prior to the implementation of the BPCI Advanced Participation Agreement. Answer: No. Nominations do not require an organization to participate in BPCI Advanced. Similarly, filing an application does not guarantee the selection of candidates to participate. Participation in the model requires a signed and executed BPCI Advanced participation contract. CMS only enters into an agreement when applications have been reviewed and applicants have passed multiple levels of program integrity and law enforcement monitoring. 5.
Question: Can you clarify… gainsharing/NPRA Shared Payments? This article by partners Deborah Gersh and Michael Lampert was published by Law360 on February 5, 2018. Answer: Regardless of the hierarchy of the assignment described above, a hospital participating in the RJC in one of the 34 mandatory metropolitan statistical zones (AMAS) or a hospital in one of the 33 voluntary MSOs, which are “einoptin” until 31 January 2018, in accordance with the current CJR rules, before a PGP participating in BPCI Advanced until 31 January 2018. (For all other 31 clinical episodes, a PGP has priority over a hospital participating in the RJC that also participates in BPCI Advanced for these clinical episodes.) Until September 30, 2018, when the original BPCI is scheduled to end, clinical episodes of the original BPCI continue to prevail over clinical episodes of the RJC. Hospitals currently participating in the original BPCI and in a mandatory ASM will become participating hospitals in the JRC from the end of the BPCI from October 1. These hospitals still have the option to apply for the remaining 31 clinical episodes for bpCI Advanced. 6. Question: Can an episode initiator request the participation of several participants and/or non-organizers? Answer: CMS plans to publish target price specifications “in the coming weeks.” The participation agreement sets out certain requirements that must be met when the participant enters into an NPRA sharing agreement. Answer: According to the CMS, the BPCI Advanced model was developed on the basis of the knowledge and success of the original BPCI. CMS wanted to provide forward-looking objective prices, add a risk adjustment element and make the model an advanced PPG by linking payments to quality. CMS also hoped that model awards would recognize and not penalize the efficiency performance of current BPCI award winners. The inclusion of all these functions in a pricing approach that included post-acute care providers as episode initiators proved to be too demanding.
Background: The Comprehensive Care for Joint Replacement (CJR) model tests bundled payments and quality measures for treatment episodes related to lower limb joint replacements (LEJRs) (i.e., hip and knee replacement). Under BPCI Advanced, clinical episodes are attributed to the episode initiator (EI) level. The hierarchy for the allocation of a clinical episode between different types of IS in BPCI Advanced is as follows, in descending order: (1) of the PGP, which presents a claim containing the national supplier ID (NPI) for the treating physician; (2) the PGP which asserts a right including the IPI of the operating physician; and (3) the ACH that provided the services that triggered the clinical episode.