what is bpci medicare

What does BPCI stand for in healthcare?

Bundled Payments for Care Improvement Initiative (BPCI) (Updated from August 13, 2015) Overview. The Bundled Payments for Care Improvement initiative (BPCI) is comprised of four broadly defined models of care, which link payments for multiple services beneficiaries receive during an episode of care.

When does a provider become responsible for a BPCI patient?

The moment a BPCI-A eligible patient is admitted to the inpatient or outpatient setting the provider becomes responsible for the outcomes and expenditures associated with the care episode. The earlier the patient is identified as a BPCI-A patient, the sooner care management and cost containment can begin.

Does BPCI improve quality and cost?

There is clear evidence that BPCI participants that included surgical procedures in their bundle have achieved both cost and quality improvements, but more progress needs to be made in bundles focused on chronic conditions.

What is the BPCI Advanced payment program?

Specifically, under BPCI Advanced, CMS may make payments to Model Participants or Model Participants may owe a payment to CMS after CMS reconciles all non-excluded Medicare FFS expenditures for a Clinical Episode against a Target Price for that Clinical Episode.

What is bpci insurance?

Bundled Payments for Care Improvement (BPCI) Initiative: General Information. The Bundled Payments for Care Improvement (BPCI) initiative was comprised of four broadly defined models of care, which linked payments for the multiple services beneficiaries received during an episode of care.

What does bpci-a mean?

Bundled Payments for Care Improvement AdvancedThe Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is a new iteration of the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (Innovation Center) continuing efforts in implementing voluntary episode payment models.

Is bpci mandatory?

With the looming financial pressure, CMMI announced that BPCI-A, a voluntary per episode payment model, would become mandatory beginning January 1, 2024.

What is the difference between bpci and bpci advanced?

Some key characteristics of BPCI Advanced that are different from BPCI are first, there will be a reduced number of clinical episodes offered in BPCI Advanced, but it will also include three outpatient clinical episodes. Second, BPCI Advanced will be an advanced APM.

Why is bpci important?

Because BPCI-A qualifies as an advanced alternative payment model (APM) under the Medicare Access and CHIP Reauthorization Act (MACRA), physicians participating in a BPCI-A bundle can earn additional Medicare Part B payment when outcomes surpass benchmark targets. Shared savings incentives.

When did bpci-a start?

BPCI Advanced is built on the foundation of the Bundled Payments for Care Improvement (BPCI) initiative, which began in April 2013 and is scheduled to run through September 30, 2018. The Model Performance Period of BPCI Advanced will start on October 1, 2018 and run through December 31, 2023.

What are bpci a diagnosis?

BPCI-A is an Advanced Alternate Payment Model (APM) in which healthcare providers agree to receive a single payment for physician, hospital and other healthcare services for specific diagnoses within an episode of care.

What are the benefits of Bundled Payments in healthcare?

Table 1Potential AdvantagesAffected PartyDecrease health care costsPayersImprove care coordinationPatientsDiscourage unnecessary carePayers, PatientsStrong incentive to avoid complications and readmissionsPayers, Patients10 more rows

How do Bundled Payments work in healthcare?

A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test, or procedure.

What is bundled payment reimbursement?

A bundled payment model is a method of reimbursement in which a single, comprehensive payment is made for a solitary episode of care. Multiple providers delivering care during this episode are paid in one lump sum, as well as payment made to the hospital/facility.

What are value based programs?

What are the value-based programs? Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for.

Are Bundled Payments working?

Bundled payments have had a predominantly positive effect on medical spending and quality of care. Bundled-payment models have had predominantly positive impacts on both spending and quality of care, irrespective of country, medical procedure, or condition and applied research methodology.

What is BPCI advanced?

The Bundled Payments for Care Improvement Advanced ( BPCI Advanced) Model is the new iteration of BPCI. The new model aims to build on the successes of BPCI, while making modifications to correct deficiencies in the old program. Some key differences include:

What is BPCI in healthcare?

Bundled Payments for Care Improvement (BPCI) was an initiative created by the Center for Medicare and Medicaid Innovation (CMMI) to test the efficacy of several different episode-based payment models in producing higher quality, moore coordinated health care at a lower cost to Medicare. BPCI was launched in 2013 concluded in 2018.

What is bundled payment?

Bundled payments provide a single, comprehensive payment that covers all services provided during a patient’s episode of care (services provided to a beneficiary with a medical condition within a specific time frame and across the continuum of care).

When was BPCI launched?

BPCI was launched in 2013 concluded in 2018. The BPCI Advanced Model is a new iteration of the program and a continuation of efforts to implement episode-based payment models, also referred to as bundled payments.

How to thrive under bundles for chronic conditions?

In order to thrive under bundles for chronic conditions, hospitals will have to take a more proactive approach and tackle non-clinical issues that feed into chronic conditions, including social determinants, though most currently lack the mechanisms to do so.

What is BPCI in Medicare?

The Bundled Payments for Care Improvement (BPCI) initiative was comprised of four broadly defined models of care, which linked payments for the multiple services beneficiaries received during an episode of care. Under the initiative, organizations entered into payment arrangements that included financial and performance accountability for episodes of care. These models aimed to increase quality and care coordination at a lower cost to Medicare. For results of these models, please see the Evaluation Reports below.

What is the BPCI initiative?

The Center for Medicare and Medicaid Innovation (Innovation Center) developed the BPCI Initiative in order to assess whether the models tested resulted in improved patient care and lower costs to Medicare.

What is CMS model 4?

In Model 4, CMS made a single, prospectively determined bundled payment that encompassed all services furnished by the hospital, physicians, and other practitioners during an episode of care, which lasted the entire inpatient stay. Physicians and other practitioners had the option to submit “no-pay” claims to Medicare and receive payment from the hospital out of the bundled payment. The bundled payment amount included related readmissions for 30 days after hospital discharge. Participants could select up to 48 different clinical condition episodes to test in the model.

What is model 2 Medicare?

Model 2 involved a retrospective bundled payment arrangement where actual expenditures were reconciled against an episode of care’s target price. Under this payment model, Medicare continued to make fee-for-service (FFS) payments to providers and suppliers who furnished services to beneficiaries in Model 2 episodes. The total expenditures for a beneficiary’s episode was later reconciled against a bundled payment amount (the target price) determined by CMS. CMS then issued a payment or a recoupment reflecting the aggregate performance compared to the target price. In Model 2, the episode of care included a Medicare beneficiary’s inpatient stay in the acute care hospital, post-acute care, and all related services during the episode of care – 30, 60, or 90 days after hospital discharge. Awardees selected up to 48 different clinical episodes to test in the model.

How long does a patient stay in the hospital in Medicare model 2?

In Model 2, the episode of care included a Medicare beneficiary’s inpatient stay in the acute care hospital, post-acute care, and all related services during the episode of care – 30, 60, or 90 days after hospital discharge. Awardees selected up to 48 different clinical episodes to test in the model.

What is episode of care in Medicare?

In Model 1, the episode of care was defined as the inpatient stay in the acute care hospital. Medicare paid the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program.

What is an awardee in BPCI?

In BPCI, an Awardee is the entity that assumes financial liability for the episode spending. Episode Initiators are health care providers that trigger BPCI episodes of care; they do not bear risk directly (unless they also serve as an Awardee) but participate in the model through an agreement with a BPCI Awardee.

What is bundled payment in Medicare?

Traditionally, Medicare makes separate payments to providers for each service they perform for beneficiaries during a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings.

What is episode initiator?

Episode Initiators are healthcare providers that trigger BPCI episodes of care; they do not bear risk directly (unless they also serve as an Awardee), but participate in the model through an agreement with a BPCI Awardee. Conveners are entities that bring together multiple health care providers.

What is bundled payment for care improvement?

The Bundled Payments for Care Improvement initiative was developed by the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid or Children’s Health Insurance Program ...

What is convener in healthcare?

Conveners are entities that bring together multiple health care providers. These conveners can participate as either Awardees that enter into Agreements with CMS and bear risk or Facilitator Conveners that do not enter into an Agreement with CMS and do not bear risk.

What is episode of care in Medicare?

In Model 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare pays the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program.

Is MS-DRG part A or B?

All Part A services paid as part of the MS-DRG payment. All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions. All non-hospice Part A and B services during the post-acute period and readmissions.

What is an EI in Medicare?

An EI is a Medicare-enrolled provider or supplier that can trigger a Clinical Episode under BPCI Advanced. In this Model, EIs can only be PGPs or ACHs, including ACHs where outpatient procedures are performed in hospital outpatient departments (HOPDs).

How long is a BPCI clinical episode?

The Clinical Episode length will be the Anchor Stay plus 90 days beginning the day of discharge or the Anchor Procedure plus 90 days beginning on the day of completion of the outpatient procedure. Clinical Episodes are constructed to include all services that overlap the Clinical Episode window, with some exclusions.

What is BPCI advanced?

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is a new iteration of the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (Innovation Center) continuing efforts in implementing voluntary episode payment models. The Model aims to support healthcare providers who invest in practice innovation and care redesign to better coordinate care and reduce expenditures, while improving the quality of care for Medicare beneficiaries. BPCI Advanced qualifies as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

What is bundled payment?

A bundled payment methodology involves combining the payments for physician, hospital, and other health care provider services into a single bundled payment amount. This amount is calculated based on the expected costs of all items and services furnished to a beneficiary during an episode of care. Payment models that provide a single bundled payment to health care providers can motivate health care providers to furnish services efficiently, to better coordinate care, and to improve the quality of care. Health care providers receiving a bundled payment may either realize a gain or loss, based on how successfully they manage resources and total costs throughout each episode of care. A bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently because a single bundled payment will often cover services furnished by various health care providers in multiple care delivery settings.

Why is bundled payment important?

A bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently because a single bundled payment will often cover services furnished by various health care providers in multiple care delivery settings.

When will CMS start the second cohort?

The second cohort started on January 1, 2020. At this time, CMS is not planning any additional application opportunities for the Model. You can review the Request for Applications (RFA) for Model Year 3.

What is BPCI in Medicare?

Share on Pinterest. BPCI can potentially improve patient care and lower Medicare healthcare costs. The Center for Medicare and Medicaid Innovation (CMMI), also known as the Innovation Center, works with the Centers for Medicare and Medicare Services (CMS) on developing and testing new ideas. One such idea involves innovative health care payment ...

What is the BPCI Advanced?

It potentially improves patient care and lowers Medicare healthcare costs. The most recent stage in the BPCI testing model is called the BPCI Advanced. The results of the billing and payment tests suggest people are spending less time in skilled nursing facilities and getting home more quickly.

How much did Medicare lower the cost of joint replacement?

In the first year Medicare lowered the cost of a joint replacement by an average $453. The CJR was a mandatory program for care providers. Many other bundled payment programs are voluntary for service providers. Data suggests it showed typical hospitals could improve care.

What is episode of care in BCPI?

In both BCPI models, one group or organization is responsible for all the billing and spending. When a person needs care, Medicare calls this an episode of care.

What is Medicare paid for?

In the traditional models, providers are paid by Medicare for each separate service given to a person during a course of treatment or a single illness. According to CMS, the traditional payment model can lead to less coordination between healthcare providers and healthcare settings.

What is the payment model for healthcare?

There are several payment models in the United States federal healthcare system. The traditional method is Fee-for-Service (FFS), where providers are paid for each healthcare service they do, including tests. Another payment method is the capitation model, in which a contract is entered by a state, a health plan, and the CMS.

When did Medicare start testing BCPI?

Medicare started four tests of the BCPI in 2013. The first was done in 2016, with two more in 2018. The most recent report was released in June 2020. In 2018, the CMS reported that 1,547 Medicare providers and suppliers signed agreements to take part in the BCPI Advanced model.

What is BPCI-A?

BPCI-A is an Advanced Alternate Payment Model (APM) in which healthcare providers agree to receive a single payment for physician, hospital and other healthcare services for specific diagnoses within an episode of care. An episode of care is defined as an anchor stay and 90 days following the anchor stay.

What is BPCI-A program?

Healthcare providers’ success with the BPCI-A program will ultimately depend on their ability to implement the previously outlined elements and integrate BPCI-A care management into current care management efforts, such as programs aimed at reducing readmissions. By building a care management strategy with the end goal of sustainability and scalability, organizations can realize greater performance across all care management efforts, furthering their progress toward value-based care.

What is evidence based risk stratification?

Many evidence-based tools can be leveraged to perform risk stratification, although most electronic health record (EHR) platforms have already embedded this technology into their systems. Implement care management across the care continuum.

What is a Bundled Payment? (Quick refresher)

In a prior Accelerate post, we defined “bundle” as the placement of all the care for a certain procedure or series of procedures into a single bucket. The rationale for contracting for a bundle is threefold:

BPCI Advanced

On January 9th, 2018, the Centers for Medicare & Medicaid Services (CMS) announced a new bundled payment program: the Bundled Payments for Care Improvement Advanced (BPCI Advanced) CMS continues its lack of originality when it comes to naming programs. Come on, BPCI "Advanced"? Why not just go with "Super BPCI" or "BPCI Platinum Edition"? .

Differences (Compared to original BPCI program)

There are inpatient (29) and outpatient episodes (3)—BPCI only consisted of inpatient

What to do

While details are still emerging—the exact benchmarking method, for example—health systems and physician group practices should apply for the program to gain access to their own historical data. That information alone is quite valuable, even if the applicant ultimately decides not to participate.

Three last points

A group has until August to formally commit to the first phase of the program (starting October 1st, 2018)

Zac Watne

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Background

Model Overview

Key Stakeholders

Clinical Episodes

• A BPCI Advanced Clinical Episode is structured to begin either at the start of an inpatient admission (the Anchor Stay) to an Acute Care Hospital (ACH) or at the start of an outpatient procedure (the Anchor Procedure). Inpatient admissions that qualify as an Anchor Stay will be identified by Medicare Severity-Diagnosis Related Group (MS-DRGs) codes...

See more on innovation.cms.gov

Quality Measures

Additional Information