Frequently Asked Questions (FAQ)
About The
Center for Medicare & Medicaid Innovation
Bundled Payment for Care Improvement Initiative
Update / # / Question and Answer12/20 / 23 / Q / How will CMMI adjust the applicant’s proposed 2009 discounted target price for an episode to 2012, 2013, 2014? Will it re-price using actual fee-for-service rates for every service, or will it adjust using indices (e.g., PPI) projecting Medicare Part A and B expenditures into the future? Will the methodology be subject to public comment?
When will the bundle holder be told what the target price is for the year in which services are delivered?
A / The methodology for determining how the target price will be trended forward is not yet available. Awardees will be made aware of this methodology prior to entering into an agreement with CMS.
12/20 / 22 / Q / How will the commitment to accept the bundle and target price be “closed”? Will the “bundler” have an opportunity to negotiate or refuse the CMS modeled target price?
A / CMS and the awardee must enter into an awardee agreement prior to the initiation of the program.We would anticipate that potential awardees would enter into discussions with CMS prior to entering into final awardee agreements.
12/20 / 21 / Q / When and at what intervals will CMS settle up with the bundler? Will it be one quarterly, at the end of the year or on a case by case basis?
What information will be provided to the bundler at the time of settlement to document any differences by case between actual payments and target price?
A / Information regarding the periodicity of the episode reconciliation, and the communication surrounding the episode recommendation is not yet available. This information will be made available to awardees prior to entering into agreements with CMS.
12/20 / 20 / Q / Hospice files are not included in the list of Standard Analytic Files that will be released by CMS for analysis to arrive at the target price. Does this mean that hospice Part A payments are excluded from the bundle?
- If so, will CMMI treat hospice as a service that truncates the episode?
- Will truncated episodes be subjected to prorated payment? Or will the bundler receive the full bundled price. What would the methodology be?
- If hospice is included in the bundle, will CMMI include the data in the data release?
A / Part A hospice services are considered an excluded Part A service in this initiative. Like other excluded services (i.e. excluded readmissions), this service would continue to be paid according to standard FFS procedures and should not be included in the target price. It would not truncate an episode. You are correct that hospice files are not included in the Limited Data Set provided through this initiative.
12/20 / 19 / Q / Will death during the episode be handled with prorated payment? Or will the bundler receive the full bundled price? What would the methodology be?
A / We apologize for the delay. We will respond to this question as soon as possible.
12/20 / 18 / Q / CMMI allows for the definition of services unrelated to the anchor hospitalization condition by permitting specific MS-DRGs and ICD-9 codes in principal diagnosis position on claims to be excluded from the bundle—presumably one would exclude the claims associated with these codes from the cost analysis.
There may be hundreds of MS-DRGs and thousands of ICD-9 codes that could be legitimately excluded. Is this what was intended? Listing and providing a rationale for these exclusions would be burdensome. Can ranges be used (e.g., for lower extremity procedures it would be reasonable to exclude all diagnoses and MS-DRGs related to upper extremity procedures, head and neck procedures, eye and ear conditions, psychiatric conditions, etc).
A / Yes, we do intend for the applicant to provide a complete list of excluded MS-DRGs and ICD-9 codes. We are aware that that this could be a very long list, and therefore applicants are welcome to exclude by ranges.
12/20 / 17 / Q / Will CMMI accept other coding (e.g., HCPCS) for exclusions to identify unrelated services? For example:
- A patient is receiving a course of chemotherapy and radiotherapy for a malignancy prior to admission to the hospital for a fracture which is subject to episode payment. Can the therapies related to the malignancy be excluded by excluding the range of HCPCS codes used to represent chemotherapy agents and drug administration?
- A patient is receiving an expensive Part B biologic for a chronic illness, and is admitted to the hospital for a joint replacement subject to episode payment. Can the HCPCS code for the biologic drug be used to exclude the costs of the drug. If some provision is not made for this, an incentive will be created to cost shift to Part D drugs whose costs are not included in the episode.
- In physician claims, diagnosis codes are placed on each line with a service. Therefore diagnosis codes appear in both the header on the claim—principal and other diagnosis positions –and on the line with the service. For payment purposes, for drugs for example, the relevant diagnosis may be required to be placed on the line and may not appear in the principal position.
A / We are not able to accept other coding (e.g. HCPCS) to identify excluded, unrelated services. These must be defined by principal ICD-9 diagnosis codes or MS-DRG.
12/20 / 16 / Q / CMMI is releasing data for residents of HRCs. Some facilities may operate in border regions or in regions with “snowbird” populations that are part time residents. While the HRCs incorporate cross state areas in some cases, facilities developing proposals where any significant proportion of patients are residents outside the counties in the HRCs will not have utilization data in their models.
- Will CMMI make any accommodation for eligibility for the bundle when patients are not residents of the region serviced by the bundler?
- Will a patient moving to another geographic area be considered grounds for truncating the bundle or qualify as an interruption of care such that bundled payment be adjusted. These issues become particularly important with longer duration episodes, which include the costs being tracked for 30 days after the end of the episode.
A / A beneficiary is included in an HRC based on where that beneficiary resides. Therefore, in the scenario you describe, applicants had the opportunity to request data for HRCs in which their beneficiaries reside even if the facility itself is not located in that same HRC. In all models, all beneficiaries eligible for the episode (identified via MS-DRG) must be included in the bundled payment. Applicants are not able to propose excluding beneficiaries because of their location of residence. Similarly, applicants are not able propose excluding beneficiaries who move during the episode or truncating the episode for that reason.
12/20 / 15 / Q / CMMI indicates that the bundler will need to settle up post-episode payments that exceed some amount determined by CMMI.
- Will the services counted in the post-episode 30 day period be the same as those included in the episode definition (e.g., including the exclusions defined for the episode)? If not, what services will be counted and how will CMMI determine these services?
A / CMS or its contractor will measure care provided during a 30 day post-episode monitoring period to ensure the aggregate Medicare Part A and Part B spending for included beneficiaries does not increase as a result of this initiative. Aggregate Medicare Part A and Part B expenditures for included beneficiaries (that is, all Medicare Part A and Part B services, not only the services in the episode definition) during the post-episode monitoring period will be compared to a historical baseline that has been trended over time and which will include a risk threshold.
12/20 / 14 / Q / What methodology will CMMI use to determine the base price against which actual payments are compared for this post-episode period? Will it be a mean for a specific geographic area? Other method?
A / The methodology for determining the historical baseline payment, trending that forward, and determining a risk threshold is not yet available.
12/20 / 13 / Q / Will CMMI be providing any ongoing information to the bundler to show the range of services that bundled beneficiary cases utilized post-episode? Bundlers will likely find it difficult to manage care both within and after the episode if they have no access to information about the range of services the patient is receiving. Will the bundler be provided access to the Central Working File in real time to monitor utilization?
A / In the application form, applicants are encouraged to describe their ongoing data needs. We would encourage you (or, the applicants with whom you are working) to include such data needs as the one you describe above in the application form.
12/20 / 12 / Q / In the RTI studies performed for ASPE, a “clean period” was used to qualify an anchor hospitalization, in which a 30 day period prior to a hospitalization was free of any hospitalization to ensure that an anchor hospitalization was not a “re-admission”. Will it be possible to define episodes in this initiative to include a “clean period”?
A / In this initiative, applicants are not able to propose a “clean period” in their episode definition.
12/20 / 11 / Q / When a re-admission occurs that is not related to the anchor hospitalization or the PAC bundled services, are there circumstances when it truncates the episode, rather than just count as an exclusion.
- For example, a joint replacement discharge with a complex medical history including risk for cardiac and vascular problems experiences a stroke while in a PAC episode which entirely changes the patient’s condition. The PAC episode pre-stroke no longer relates to the care required after the stroke. Does the stroke hospitalization truncate the initial PAC episode and trigger another PAC episode related to the stroke hospitalization as an anchor hospitalization?
A / In this initiative, applicants have the opportunity to define excluded readmissions by MS-DRG and excluded unrelated Part B services (identified by principal ICD-9 diagnosis codes designated as unrelated). In the scenario you describe, the applicant could propose that readmission and then the associated post-acute care (as identified by ICD-9 principal diagnosis code) could be defined as excluded, and would not truncate the episode. We do not anticipate a scenario in which an episode would be truncated by a certain readmission.
12/20 / 10 / Q / Will CMMI consider any condition or adjustment to bundled payment for patients with dementia, particularly in proposals where the bundler has programmatic expertise in working with dementia patients? Would CMMI require research showing the potential impact of cost for dementia patients?
Will CMMI consider applications that include payment adjustments to episodes for particular anchor hospitalizations based on data that shows differences in costs driven by patient characteristics or clinical features of the case? Would this fall under risk adjustment?
- For example, the major joint replacement MS-DRGs do not distinguish between hip and knee replacements, though it is simple enough to use the ICD-9 procedure codes to distinguish between hip and knee replacements as well as total and partial replacements. Data also shows that elective and trauma cases have different cost structures and duration. Can such a distinction which can be made using coding be used to document a payment adjustment. Note we are referring to payment adjustments rather than “risk adjustment”: the former being a more narrow feature of payment tied directly to data showing cost differences for a small group of patients, rather than typical risk adjustment methods that apply to a broader population.
A / Episodes must be defined by MS-DRG and may not further be defined by ICD-9 codes. In all models, CMS will consider applicant proposals around risk adjustment, which must include a description of the methodology and may include plans for updating risk adjustment on a yearly basis based on new information.
11/10 / 9 / Q / Am having difficulty with encrypting signatures and submissions. Is encryption required?
A / In light of our upcoming deadline for submission of Model 1 applications (November 18, 2011, 5:00 PM EDT), and the Models 2-4 application deadline (March 15, 2012, 5:00 PM EDT) we would like to provide updated information regarding encryption: Applicants are no longer required to encrypt the Models 1-4 applications, any attachments or the submission email. Should you wish to encrypt your application materials or email when submitting this information to CMS, you are still welcome to do so. If you have already submitted encrypted application materials for Models 1-4, no action is necessary at this time and there is no need to resubmit these materials. Please note that all other instructions regarding submission of application materials remain the same. Please see each application form for specific instructions.
11/2 / 8 / Q / Is it possible to add additional users to the DUA after the November 4th deadline? Am still trying to identify a vendor to assist in the analysis of CMS data.
A / It is possible to add additional data users to the DUA using the DUA signature addendum after the November 4th deadline. The applicant can share the data with other parties (such as a consultant you later identify), in accordance with section 9 of the Data Use Agreement, provided that those parties have all signed the DUA or a DUA signature addendum and have had that document accepted by CMS (by submitting the DUA or addendum to the email address and awaiting confirmation). Submitting additional DUA signature addenda can happen after the November 4th deadline.
11/2 / 7 / Q / My email submission bounced back. One of the attachments is very large (21MB), and am not sure why. Are there any alternative ways of sending in my submission.
A / We are sorry about the difficulties you are experiencing.
- All files must be submitted via email. No CDs or DVDs will be accepted. The form we have them posted on our website, the largest file is 1.7 MB. If the documents are significantly larger due to the process of printing and scanning them, or saving them, we would recommend examining the properties of the document to see if it can be compressed at all. Lower quality documents will be accepted as long as they can still be read.
- You can split the submission email into multiple emails with separate attachments, if needed. You should include in the email a list of documents that are attached to that email, as well as those that will come in other emails.
- The Research Request Packet is the largest file, and the ‘appendix’ does not have to be submitted. If the applicant would like to remove this appendix when saving the file for submission, that would be acceptable.
9/9 / 6 / Q / What methodology will CMS use to trend forward target prices? (September 9, 2011)
A / CMS’s methodology for trending forward target prices will be determined after applications are received and prior to awards being made. Please use data from calendar year 2009 for your historical payments, and propose a target price in calendar year 2009 dollars. CMS will trend proposed target prices to calendar year 2012 dollars for purposes of final agreements with awardees. The target price will be further trended forward in subsequent years of the performance period.
10/26 / 5 / Q / How will the target price be determined?
[AHCA: Our vendor assisting us on the bundled payment initiative provides the following comments:]
The application instructions direct the applicant to document the historical payments for their proposed episode definitions based on 2009 data, and to propose a target price in 2009 dollars. The target price must include a 2-3% minimum discount depending on the duration of the episode proposed. What is never explained in detail in the CMMI materials is how CMS will adjust the proposed target price for 2012, 2013 and future years. Not having this information leaves applicants at risk for whatever adjustments CMS makes. There are provisions in the application process for submitting questions to CMMI, and those considering submitting letters of intent may want to go ahead and submit questions on this issue so that CMMI can provide guidance well in advance of the application deadline.