Comprehensive Care for Joint Replacement Model Reconciliation Overview

 
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
undefined
 
Payment
 
and
 
Repayment
 
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
undefined
 
Reconciliation
 
Updates
 
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
undefined
 
Data
 
and
 
Reports
 
Files
 
on
 
the
 
Data
 
Portal
 
PY5.2
 
Final
 
Reconciliation
 
Report
 
Report
 
Demo
(screen
 
share)
undefined
 
Appeals
 
Process
 
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
 
CE
 
notice
submitted
within
 
45
days.
 
CMS
 
response
within
 
30
days.
1
 
If
 
no
 
request
submitted,
payment
 
or
repayment
proceeds.
 
2nd
 
Level
 
Appeal
 
Request
 
for
reconsideration
review
submitted
within
 
10
 
days.
 
Reconsideration
review
 
scheduled
within
 
15
 
days.
 
CMS
 
review/
response
within
 
60
days.
1
 
Written
determination
is
 final.
Payment
 
or
repayment
proceeds.
 
1
CMS
 
reserves
 
the
 
right
 
to
 
extend
 
the
 
review
 
period
 
upon
 
notice.
undefined
 
Reconciliation
 
Review
 
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
 
50
th
 
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
 
Review:
 
CQS
 
Ranges
 
&
 
Discount
 
Factors
 
Review:
 
Stop-
gain/loss
 
Across
 
PYs
 
*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
 
“real
 
dollars”
 
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
undefined
 
Thank
 
you
 
for
 
joining
 
us.
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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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  1. PY5.2 Final Reconciliation Overview Comprehensive Care for Joint Replacement Model June 5, 2023 2:00 PM

  2. Agenda 1. Announcements 2. Payment and Repayment 3. Reconciliation Updates 4. Data and Reports 5. Appeals Process 6. Reconciliation Review

  3. 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

  4. 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

  5. Payment and Repayment

  6. Payment Timing Approximate timing of payment delivery August for those not appealing November for those appealing

  7. 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

  8. 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

  9. 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

  10. 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

  11. Reconciliation Updates

  12. 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

  13. PY5.2 Final Reconciliation PY5.2 Final reconciliation accounts for: Final claims run-out Claim/episode cancellation Excess post-episode spending ACO overlap

  14. 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

  15. Data and Reports

  16. 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

  17. PY5.2 Final Reconciliation Report Report Demo (screen share)

  18. Appeals Process

  19. 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))

  20. 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

  21. 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

  22. 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.

  23. Reconciliation Review

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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)

  33. 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

  34. 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

  35. 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

  36. Thank you for joining us.

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