Bundled Payments for Care Improvement Advanced Program Compliance. To Receive CPE Credit. Individuals. Groups

Transcription

1 Bundled Payments for Care Improvement Advanced Program Compliance BKD National Health Care Group November 19, 2018 To Receive CPE Credit Individuals Participate in entire webinar Answer polls when they are provided Groups Group leader is the person who registered & logged on to the webinar Answer polls when they are provided Complete group attendance form Group leader sign bottom of form Submit group attendance form to within 24 hours of webinar If all eligibility requirements are met, each participant will be ed their CPE certificate within 15 business days of webinar 1

2 Presenter Sarah Bixby, MBA, MHA Senior Consultant Today s Topics Value-Based Care Reimbursement BPCI-A Program Overview Regulatory Requirements 4 Program Compliance 2

3 Fee-for-Service to Value-Based All Medicare FFS (Categories 1 4) FFS linked to quality (Categories 2 4) Alternative payment models (Categories 3 4) % 50% 85% %06 All Medicare FFS All Medicare FFS BKD National Health Care Group Recent Changes from CMS CMS proposed changes to MSSP Transitions participants to two-sided risk under a phase in approach Introduction of Bundled Payments for Care Improvement Advanced (BPCI-A) Expanded voluntary bundled payments opportunity Adds additional options for organizations to take on risk CJR compliance survey released CMS indicates likely to expand oversight of program compliance 3

4 Implications of Changes Be prepared Key Impacts Hospitals will be pressured to take on downside risk & improve performance Markets will become increasingly competitive as two-sided risk picks up & costs are reduced Consolidation due to organizations not able to take on risk alone Pain points specific to profitability due to FFS payments but two-sided risk participation Increased oversight regarding program compliance BPCI-A Overview 4

5 BPCI-A Overview Bundled Payments for Care Improvement Advanced (BPCI-A) Voluntary bundled payments model FFS payments with retrospective reconciliation Can participate as a convener or nonconvener participant Beneficiaries who can receive Part A & are enrolled in Part B with Medicare as their primary payer Beneficiaries not covered under United Mine Workers or managed care plans Not included in Medicare based on basis of ESRD Episode of Care Episodes begin with discharge of eligible Medicare beneficiaries with selected diagnoses Inpatient clinical episodes 29 Outpatient clinical episodes 3 Episodes include related items & services Hospitalization & 90 days post-discharge All Part A & Part B services included except services unrelated to episode 5

6 Target Pricing & Reconciliation Hospitals & providers in the program will continue to be paid on a FFS basis For each performance year, payments made that fall within the BPCI-A Episode of Care will be compared to a target price for a hospital In general, if Actual spending < target price then reconciliation payment Actual spending > target price then repayment to CMS Regulatory Requirements 6

7 Financial Arrangement Overview Financial Arrangements Payments Subject to Sharing Cap Reconciliation payments payment from CMS to participant when they have achieved a positive net payment reconciliation amount (NPRA) Internal cost savings (ICS) verifiable & measurable cost savings related to care redesign activities provided to BPCI-A beneficiaries within clinical episode Cannot exceed NPRA payments from CMS Payments to partners/practitioners cannot exceed 50% of allowable FFS reimbursement Regulatory Requirements BPCI-A participant may enter into financial arrangements Written agreements & signed agreements with sharing partners Agreements comply with CMS financial arrangement requirements via participation agreement Program compliance necessary for protection under applicable waivers (fraud & abuse) 7

8 Regulatory Requirements Key payment requirements Sharing partners must be identified on financial arrangement list & included as a party to the sharing agreement Must meet defined quality goals described in sharing agreements Sharing agreements must include methodology & accounting formula for determining shared payments (NPRA & ICS) Satisfy documentation requirements, such as contemporaneous documentation of shared payment & ICS, e.g., amount & recipient of payments Regulatory Requirements ICS key sharing requirements Payments must come from sharing partners who agree to contribute as defined it the sharing agreement Must be engaged in BPCI-A activities which are substantially based on quality of care ICS calculation methods must be consistent for all sharing partners (can be differentiated by provider type) Payments must be maintained in BPCI-A Savings Pool & then distributed to participants 8

9 Other Program Requirements Beneficiary incentive program Must track & monitor incentives provided to beneficiaries Ensure incentives comply with CMS criteria Beneficiary notification Standard notification required to be furnished to beneficiaries Materials need to be approved by CMS Program Compliance 9

10 Shared Responsibility Participants have a compliance plan including (can leverage existing compliance plan) Written policies, procedures & standards of participation in model Designated BPCI-A compliance committee Communication program for dispensing program participation rules/regulations to partners Sharing partners & group practice practitioners Follow rules/regulations from CMS & participant organization Follow care redesign plan (actively participate) Provide services within best practice guidelines Fun Fact goes All here participants and draws in special the BPCI-A attention model are responsible to the slide for program highlight. compliance Where to Start? Compliance assessment Gap analysis Monitoring & support Including review of Relationships for FMV compliance Quality performance Cost savings Beneficiary incentive program (if applicable) Beneficiary notification Other necessary program requirements (data sharing/waiver compliance) 10

11 Cost Savings Calculations Key Considerations Appropriately establish a baseline for costs, specific to the bundle under consideration Establish a methodology to capture & calculate cost savings Cases used for cost savings should tie to those included in the reconciliation payment Should be easily verifiable & replicable Should be reasonably related to the actions of the physicians Savings base needs to reflect administrative costs incurred to achieve the savings (payments should be based on net savings) Should be paid as earned, subject to reconciliation Payments should be contingent on achieving baseline quality scores consistent with prior periods Compensation caps should be considered to disincentivize large volume shifts Program Compliance Monitoring Key takeaways Ongoing review of internal controls Review of policies & procedures to track distributions Review ICS methodology to verify participant s savings Collect & analyze data to inform performance & program opportunities Verify mechanisms for identifying compliance problems 11

12 Compliance Considerations Understand what the role of compliance is in your organization As it specifically relates to bundled payment programs Do you need to expand the scope of your program compliance oversight? Record retention (10 years) Quality measurement Gainsharing regulations Waivers Beneficiary protections Compliance training Are you prepared? Do you understand compliance implications? 12

13 Continuing Professional Education (CPE) Credit BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: CPE Credit CPE credit may be awarded upon verification of participant attendance For questions, concerns or comments regarding CPE credit, please the BKD Learning & Development Department at training@bkd.com 13

14 Stay Connected Last year, BKD published 100+ health care articles, webinars & tools Subscribe to Health Care, Home Care & Hospice & Long-Term Care & Senior Living newsletters to stay informed bkd.com/subscribe The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered 14