Comprehensive Care for Joint Replacement Model Reconciliation Overview
This presentation covers the final reconciliation overview for the Comprehensive Care for Joint Replacement Model. Topics include announcements, payment and repayment details, reconciliation updates, data and reports, appeals process, and reconciliation review. Key updates for 2023 are highlighted, outlining payment timing, necessary information accuracy, and the payment process facilitated by National Government Services. Repayment procedures are also provided for those owing payments.
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PY5.2 Final Reconciliation Overview Comprehensive Care for Joint Replacement Model June 5, 2023 2:00 PM
Agenda 1. Announcements 2. Payment and Repayment 3. Reconciliation Updates 4. Data and Reports 5. Appeals Process 6. Reconciliation Review
Announcements PY5.2 Final Reconciliation Report available on the CJR Data Portal as of May 11, 2023 2022 Reconciliation Report available separately Monthly data feed no longer includes Performance Year Subset (PY) 5.2 episodes as a result of PY5.2 final reconciliation Send questions regarding today s webinar materials to CJRSupport@cms.hhs.gov
Updates for 2023 Unlike recent years, this reconciliation covers only one performance year subset: PY5.2 Your payment or repayment will be the net difference between your PY5.2 final and initial reconciliation amounts Payments or repayments for PY5.2 final reconciliation will occur separately from PY6 reconciliation
Payment Timing Approximate timing of payment delivery August for those not appealing November for those appealing
Your Information Must be correct in Medicare Provider Enrollment, Chain, and Ownership System (PECOS) Banking details Contact person name and address Ensures payments are received and repayments don t accrue unnecessary interest
Payment An independent payment contractor, National Government Services (NGS), facilitates the reconciliation process Payments are made via USBank Not regular Medicare Administrative Contractor (MAC) The first addenda line on the EFT remit will show: *ZZ*CMMI IPC NGS *ZZ*USBANK One payment with separate addenda lines showing which Medicare Trust Funds were drawn from: CMS-CJR-A CMS-CJR-B Total payment will reflect the sum of the CMS-CJR-A (Part A) and CMS-CJR-B (Part B) lines
Repayment If you owe a repayment: You will receive a demand letter at your hospital s mailing address of record that will include information on how to submit payment If you wish to pay the amount due prior to receiving the demand letter repayment, instructions will be included in: The email notification of the availability of the reconciliation reports, and The reconciliation report itself
Payment Offset You may receive a payment less than the amount shown in your reconciliation report Due to an outstanding CJR model debt or unpaid interest from a previous PY, either from your CCN or another CCN that shares the same TIN Due to a current CJR model repayment owed by a CCN that shares the same TIN Outstanding amount is netted against the reconciliation payment For example: PY5.2 final reconciliation payment amount $8,000 PY5.1 final outstanding debt/interest -$5,000 EFT remit 3,000
Episode Period and Runout Date PY5.2 Final Episodes that ended January 1 September 30, 2021 Some episodes will have begun in late CY 2020 Includes episode periods (indicating applicable target prices): 10/1/2020 - 12/31/2020 and 1/1/2021 - 7/3/2021 Uses claims processed into the CMS IDR as of December 1, 2022
PY5.2 Final Reconciliation PY5.2 Final reconciliation accounts for: Final claims run-out Claim/episode cancellation Excess post-episode spending ACO overlap
PY5.2 Final Reminders Shorter 9-month performance year subset Stop gain/loss at 20%, or 5% for rural entities Capped spending for all episodes starting on or before March 31, 2021 due to COVID-19 PHE Capped spending for episodes with a COVID-19 diagnosis starting after March 31, 2021 Episode spending and target prices adjusted during reconciliation to reflect the suspension of Medicare sequestration
Files on the Data Portal File Contains Claims and beneficiary data for PY5.2 episodes, using run- out dates for reconciliation PY5.2F Reconciliation Claims Data.zip PY5.2F Reconciliation Reports.zip Reconciliation HTML report, summary data files, quality measure summary file, and calculation error (CE) form and instructions Archived Reconciliation Reports.zip Archived Reconciliation Reports zip file from 2022 reconciliation (PY5.1F/5.2I) PRO Hospital-Specific Report.zip Hospital-Specific Report (HSR) providing detailed measure results for hospitals that did not successfully submit Patient Reported Outcomes (PRO) data README & Data Dictionary.zip Specifications and data dictionary, quality measure deciles, and log of changes
PY5.2 Final Reconciliation Report Report Demo (screen share)
Submitting an Appeal To dispute payments matters, hospitals must submit a notice of calculation error (CE) within 45 calendar days of reconciliation report issuance date DUE: June 24, 2023 11:59 pm ET CE form must be emailed to CJRreconciliation@cms.hhs.gov Only hospitals may submit appeals Limited to PY5.2 episodes only Note that there is no administrative or judicial review for topics such as model design or scope (see 42 CFR 510.310(d))
Sending PII/PHI Need to send PII or PHI? Upload notice of calculation error (CE) form or other documentation with PII/PHI to the CJR Data Portal Email notification of upload to CJRreconciliation@cms.hhs.gov See CE Form Instructions in CJR Data Portal for additional instructions
Types of Calculation Errors Including or excluding Medicare beneficiaries or episodes in the baseline or PY Including or excluding specific claims within episode spending in the baseline or PY Reconciliation amount calculation error Applying or using the composite quality score (CQS) during reconciliation or in determining the performance decile
Submitting an Appeal 1st Level Appeal If no request submitted, payment or repayment proceeds. CE notice submitted within 45 days. CMS response within 30 days.1 2nd Level Appeal Written determination is final. Payment or repayment proceeds. Request for reconsideration review submitted within 10 days. CMS review/ response within 60 days.1 Reconsideration review scheduled within 15 days. 1CMS reserves the right to extend the review period upon notice.
Review: CJR Regulations Reconciliation amounts calculated according to methods described in 42 C.F.R. 510, 512 Published in the CJR Original Final Rule Revised in the EPM Final Rule enacting minor modifications, the CJR/EPM Voluntary Participation and other changes Final Rule, the April 2020 COVID-19 Interim Final Rule with Comment Period (IFC), the November 2020 COVID-19 IFC, and the May 2021 CJR Model Three-Year Extension, Episode Definition and Pricing Changes Final Rule Regulations and notices can also be found on https://innovation.cms.gov/initiatives/CJR
Review: Excluded Episodes Three examples of excluded episodes: Beneficiary covered by Medicare health plans that are not traditional fee- for-service, including Medicare Advantage and other plans Beneficiary date of death during the episode Readmitted for another anchor stay For more details see: Episode Definition Specifications and the DROPREASON variable in the Data Dictionary EPIEXC file in PY5.2F Reconciliation Claims Data.zip, containing excluded episodes and applicable DROPREASON(s) 510.205: Beneficiary inclusion criteria 510.210: Determination of the episode
Review: Episode-level Adjustments The following adjustments will be made to total episode cost: Including non-claims-based payments (NCBPs) from CPC+ and PCF in episode spending Capping episode payments for episodes that occur during an emergency (including those from January 31, 2020 through March 31, 2021) or that include a claim with a COVID-19 diagnosis Capping episode payments at the high-cost threshold Inpatient payment reflects Medicare DRG payment adjustment for hospital acquired conditions For more info, see the Episode Definition Specifications in the README zip file
Review: Prospective Target Prices CMS establishes episode target prices for participant hospitals each PY The prospective target prices: Are updated at least 2x/year to account for Medicare payment updates Apply based on anchor stay admission date Assume a 3% discount for quality For applicable prospective target prices, reference EPISODE_PERIOD (or anchor begin date) against the target price file
Review: Adjustments to Target Prices Reconciliation adjusts the standard 3% discount used for prospective target prices based on quality Higher quality category = smaller discount See Table 4 in the Reconciliation Report For quality-adjusted target prices, see QA_STD_TP in hospital reconciliation summary file (HOSP_RECON_SUM) Reconciliation applies wage factors from prospective target prices Uses the IPPS Impact File that was available when the prospective target prices were created
Review: Quality Performance Points Quality measure performance points + improvement points + PRO submission points = Composite Quality Score (CQS) Quality measure performance points are based on quality measure results (Tables 5/6 of Reconciliation Report) Points are assigned based on performance percentile CMS assigns hospitals without reportable quality measure values to the 50th percentile PRO data for PY5.2 is based on an eligible THA/TKA procedure window between July 1, 2019 June 30, 2020 For detailed information, refer to the QM file
Review: CQS Points Quality Performance Weight (%) Max Points THA/TKA Complications measure (NQF #1550) 50 10.0 HCAHPS Survey measure (NQF #0166) 40 8.0 THA/TKA voluntary PRO and limited risk variable data submission 10 2.0 Quality Improvement Max Points THA/TKA Complications measure (NQF #1550) 1.0 HCAHPS Survey measure (NQF #0166) 0.8
Review: CQS Ranges & Discount Factors Reconciliation payment eligible CQS Quality category PY5.2 discount factor > 15.0 Excellent 1.5 Yes 15.0 and 6.9 Good 2.0 Yes < 6.9 and 5.0 Acceptable 3.0 Yes 3.0 (repayment only) < 5.0 Below Acceptable No
Review: Stop-gain/loss Across PYs PY Stop-gain % Stop-loss % Protective Stop-loss %* 1 5 NA NA 2 5 5 3 3 10 10 5 4/5 20 20 5 *Protective stop-loss is applicable to: Rural hospitals Rural Referral Centers (RRCs) Medicare Dependent Hospitals (MDHs) Sole Community Hospitals (SCHs)
Review: Reconciliation (Re)Payment Your net payment reconciliation amount (NPRA) is: Difference between episode spending and the quality-adjusted target price High-cost threshold and stop-loss/gain limits applied With adjustments (if applicable) for: Excess post-episode spending Shared savings with ACO models Payment eligibility (based on quality) Reconciliation amounts are expressed in realdollars with wage factors re-introduced The overall payment or repayment listed at the top of your report is the difference between your PY5.2 final and PY5.2 initial NPRA
PY6 Reconciliation PY6 will include episodes with end dates from October 1, 2021 December 31, 2022 A single reconciliation will be held for PY6 in 2023, with run-out through July 1, 2023 First reconciliation to incorporate outpatient episodes Adjustments to target prices Risk adjustment based on age, HCC count, dual status Normalization factor to remove the overall impact of adjusting for age, dual status, and HCC count on the national average target price Market trend factor to adjust for regional spending trends Smaller discount factors for hospitals with good or excellent quality High-cost episodes are capped at 99th percentile For more information, see the CJR Model Three-Year Extension Final Rule
Reminders Send questions regarding today s webinar materials or an aspect of your reconciliation report to CJRSupport@cms.hhs.gov Inquiring about a reconciliation episode? Follow the appeals process
