Welcome to the Model 4 CABG Bundled Payment

Transcription

1 Welcome to the Model 4 CABG Bundled Payment Presentation December 11, :30 am Lance Auditorium Please sign in at the Registration table located at the back of the room. CMS BUNDLED PAYMENTS FOR CARE IMPROVEMENT BUNDLED PAYMENT MODEL 4 Coronary Artery Bypass Graft (CABG) Procedures Kim L. Carpenter, MD, FAAFP VP of Clinical Effectiveness Interim VP of Medical Affairs

2 CMS Bundled Payments for Care Improvement Agenda Historical Overview Quality Payments Contracts Gainsharing Summary References Historical The Center for Medicare and Medicaid Innovation (CMMI) was created by Congress under the Affordable Care Act (ACA) in CMMI s directive was to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care for those who get Medicare, Medicaid or CHIP benefits. In 2011, 4 Bundled Payment Initiatives (aka Models ) were introduced for voluntary participation by healthcare providers across the country. In 2014, JSUMC intends to participate in Model 4 a bundled payment program for CABG s. 2

3 Overview For Medicare beneficiaries undergoing CABG procedures ONLY. JSUMC receives reimbursement for all hospital (Part A) and physician (Part B) payments. JSUMC is also responsible for readmissions and physician fees within 30 days post discharge. Physicians must continue to submit bills to CMS. CMS will provide JSUMC with the billing information. JSUMC then pays physicians as per the usual Physician Fee Schedule. The Part B payments will be issued monthly. Overview 34 quality indicators have been embedded in the clinical care pathway. These quality parameters a e will be tracked for compliance ce and all readmissions will be reviewed. If the cost of care is less than the bundled payment, additional funds may be available for a gainsharing bonus. Participants eligible to receive a gainsharing bonus are the: CT Surgeons CT Anesthesiologists Cardiologists (Interventional and Non-Interventional) Cases where all quality indicators are100% compliant will be eligible for a gainsharing calculation. Gainsharing bonuses will be issued twice a year. 3

4 Overview Administrative oversight will be provided by the Model 4 Bundled Payment Steering Committee. The Committee is composed of physicians, administrative leaders, service line leaders, legal representation, mid-level providers, and medical management support. Clinical Quality The goal of Model 4 is to provide high quality, efficient, more coordinated care. A clinical care redesign team was developed and led by cardiothoracic surgeons, Chief of Cardiac Surgery, CT ICU Medical Director, and cardiovascular Care Managers. The Team used evidence-based research, clinical guidelines (AHA/ACCF, Society of Thoracic Surgeons, Society of Critical Care Medicine and American College of Chest Physicians), best-practice models (Geisinger s ProvenCare) and regulatory requirements to guide their clinical care redesign. Sixty-nine (69) clinical quality measures were selected for inclusion into the program. Thirty-four (34) will be implemented at the start of the program (January 2014). The remaining best practice measures will be phased-in as the program progresses. The clinical care provided to our CABG patient population will be actively monitored by a multidisciplinary team both concurrently and retrospectively to insure best practice is provided and to identify any opportunities for improvement. 4

5 Payment Methodology: Bundled Payment JSUMC will notify CMS during the patient s hospitalization that the patient is a Medicare beneficiary with a CABG via the Notification of Admission (NOA) process. CMS will acknowledge the NOA by response to JSUMC (weekly report) and designating Part B billing claims as no pay. Any claims submitted for this hospitalization or readmission 30-days post discharge will not be paid by CMS. A bundled payment will be received by JSUMC after discharge. Payment Methodology: Part B Payment JSUMC receives the Part B claims from CMS through a weekly data feed. JSUMC will pay all Part B claims from the bundled payment received from CMS. Part B Physicians must continue to bill CMS for their services. JSUMC has contracted with an outside vendor, EA Health, to provide physician payment management services. Physicians will receive checks or electronic funds transfers from this entity. EA Health will issue payments on a monthly basis to physicians. 5

6 Payment Methodology: Opt-Out You can Opt-Out of receiving your payment from JSUMC (continue to receive payment from CMS). If you do Opt-Out, you must include a specific HCPCS modifier on each line of each claim you submit to Medicare for services provided to a Model 4 CABG beneficiary. You can not Opt-Out from the Bundled Payment Program in its entirety, only via each claim submitted In the event you resubmit an Opt-Out claim to Medicare and JSUMC has already paid you JSUMC will request recoupment from you. Payment Methodology: Opt-Out HCPCS Modifier In order to decline participation in the Model 4 payment arrangement, physicians and non-physician practitioners must report the HCPCS modifier AO on each line of each claim. The modifier must be used on every claim for which the physician or non-physician practitioner wishes to decline participation. CMS contractors will process claims as fee-for-service for claims when the AO modifier is reported on every line of the claim. 6

7 Payment Methodology: Readmissions Part B claims for services provided during the 30 day postdischarge period will NOT be paid by CMS. These costs are included in the bundled payment to JSUMC. JSUMC will pay Part B services to the physicians in the same way as outlined for the initial hospitalization. Opt-Out procedure will apply for readmissions. Payment Methodology: Co-Insurance PARTICIPATING: No need to bill co-insurance. JSUMC will be reimbursing the physician 100% of the fee schedule. OPT-OUT: Bill secondary/co-insurance as per your usual process. CMS will reimburse the physician minus the estimated co-insurance amount (usually 20%). JSUMC will have to refund CMS, secondary insurers, and patients for payments made under the Opt-Out scenario. 7

8 Payment Methodology: Deductibles PARTICIPATING: No need to bill for unmet deductibles. JSUMC will be reimbursing the physician 100% of the fee schedule. OPT-OUT: Bill the beneficiary for the unmet deductible amount as per your usual process. CMS will reimburse the physician minus the unmet deductible. JSUMC will have to refund CMS, secondary insurers, and patients for payments made under the Opt-Out scenario. Payment Methodology: Recoupment Every 3 months CMS will provide JSUMC with a Reconciliation Report. This includes a summary of all claims in the preceding quarter. This report will be utilized to recoup payment from Part B Opt-Out physicians in the event you were paid by both CMS and JSUMC. This report will be used to contact Opt-Out physicians to inquire about patient payments of co-pays and deductibles. 8

9 Payment Methodology: Gainsharing Payment Calculations are made every 6 months evaluating the efficiency of the program. Savings are used to pay the program costs. If funds are left over, Gainsharing participants (CT Surgeons, CT Anesthesiologists i t and Interventional ti and Non-Interventional Cardiologists) will be paid every 6 months. Contracts/Agreements for Part B Payments CMS and the Physician Payment Management vendor requires JSUMC to have signed Agreements with participating physicians for the Bundled Payment Program. The Agreement acknowledges your understanding of the bundled payment program, the payment methodology, and associated components of the program. 9

10 Contracts/Agreements for Part B Payments Signing the Agreement signifies your participation and provides JSUMC with your practice s basic information for issuing payment for Part B services. Physicians signing this Agreement still maintain the ability to Opt-Out on a per claim basis. Physicians NOT signing this Agreement and who DO NOT Opt-Out may experience delay in payment or no reimbursement at all for services provided. Contracts/Agreements for Gainsharing In addition to participating in the Model 4 Bundled Payment Program, some physicians are eligible to participate in the Gainsharing portion of the program if: DRG-specific cost savings are realized Physician specialty is Cardiothoracic Surgery, Cardiology, or Cardiothoracic Surgery Anesthesiology Best practice quality metrics are met A separate Gainsharing Contract Agreement will be provided to those specialty physicians (available today). 10

11 Key Payment/Contracting Concepts New Payment Source JSUMC vs. CMS Minimal Delay in Reimbursement Monthly vs. 2 weeks turnaround To avoid unnecessary delays submit bills within 2-4 weeks of services provided Billing Volume Impact Low volume (CABG) vs. Usual Volume (All Dx) Agreement Required Have a signed Agreement to avoid unnecessary delays Key Payment/Contracting Concepts Full Medicare Physician Fee Received No deductibles No co-pays No co-insurance processing No patient balance billing Participation Ease No change to current CMS billing process Cumbersome Opt-Out process Cumbersome Opt Out process Financial Risk All for JSUMC vs. None for physician practices 11

12 Other Participation Benefits New Model of Payment No risk practicing Experience in new payment reform milieu Accountable Care Organization Population Health Innovation Only 2 NJ Hospitals participating in Model 4 (including JSUMC) Only 25 Hospitals nationally focusing on CABG Team approach Patient Benefits Quality Improved patient care Improved patient safety Improved clinical outcomes 12

13 Next Steps: What We Need You To Do 1. Review the Agreement 2. Sign the Agreement 3. Provide required information Joinder Page Signature Page W-9 4. Return ALL: In person: Medical Management (Brennan 109, Case Management Department) By fax: By Bundled Payment Model 4 Leadership ADMINISTRATIVE Kim Carpenter MD, VP Clinical Effectiveness Elizabeth Maiorana, Corporate Director Cardiac Services CLINICAL Rick Neibart MD, Chair Cardiothoracic Surgery Alex Rodriguez MD, Medical Director CTICU Dawn Calderon MD, Chair Cardiology FINANCIAL Marilyn Koczan, VP Patient Financial Services Cindy Diamond, JSUMC Site Finance Manager LEGAL Sharlene Hunt, Legal Counsel 13

14 Bundled Payment Model 4 Summary JSUMC Model 4 bundled payment for Medicare CABGs. Promote team work/collaboration. JSUMC receives the bundled payment. JSUMC pays the Part B charges to the physicians. Signed contracts are required before JSUMC can distribute those payments. Payments are the full Fee Schedule no deductible, no coinsurance. Quality monitored, cost reduced, savings shared. Bundled Payment Model 4 Q&A Presentation Agreement (Gainsharers Available) Application 14

15 Bundled Payment Model 4 Contact Information General Model 4 Program Inquiries Kim Carpenter, MD Agreement Inquiries (Legal) Sharlene Hunt Clinical Care Inquiries Rick Neibart, MD Alex Rodriquez, MD Janie Baranyay Payment/Billing Inquiries Marilyn Koczan Reference Documents JSUMC Physician Extranet at 15