One of the ongoing hallmarks of the Affordable Care Act is its commitment to innovation in finding new ways to deliver quality care more efficiently. Toward that end, the Centers for Medicare and Medicaid (CMS) developed several types of Alternative Payment Models (APMs), which use added incentive payments to provide high-quality and cost-efficient care for a specific clinical condition, a care episode, or a population.
One of those APMs is known as the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model. BPCI Advanced seeks to achieve five main goals: care redesign, health care provider engagement, patient and caregiver engagement, data analysis/feedback, and financial accountability. As CMS explains: “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.”
Participation in the model is voluntary, but once healthcare providers commit to being BPCI Advanced Model Participants, they are required to submit clinical and other beneficiary-specific documentation to CMS. The first cohort of participants started October 1, 2018. Shortly thereafter, in December 2018, Healthcare Management Solutions, LLC (HMS) was engaged for the BPCI Advanced Model Monitoring & Compliance Medical Record Review.
Protecting Vulnerable Populations
This review work for CMS’ Center for Medicare and Medicaid Innovation (CMMI) fits perfectly with HMS’ mission of protecting vulnerable populations.
Specifically, HMS’ BPCI Advanced review team:
- Evaluates whether or not beneficiaries in the model are being notified that their care is being provided within the BPCI Advanced program and that the notice is provided in the form and manner specified by the Model Participation Agreement.
- Investigates and evaluates the potential impact of model participation on beneficiaries’ quality of care in a BPCI Advanced-specific Clinical Episode.
- Reviews whether incentives used to promote beneficiary engagement are being administered according to the Model Waiver specifications.
- Assesses whether care redesign plans, such as realignment of care pathways or implementation of a technology solution to improve care coordination, are implemented according to each Participant’s Model profile.
- Determines whether Medicare payment policy waivers are being properly implemented. These include:
- Telehealth waiver
- Post-discharge home visit waiver
- SNF 3-day Rule waiver
HMS’ clinical staff and quality reviewers focus carefully on all BPCI Advanced activities that impact beneficiaries and their ability to maintain choice in the selection of downstream and post-acute care providers. We need to identify any adverse impact that the BCPI Advanced model might have had on the provision of beneficiaries’ care, including the potential risk of beneficiary avoidance or stinted care. They must not only have power of choice, with access to the best providers, but they also must not be turned away by those providers because their disease could cost more to treat during an episode.
Support from HMS’ Nationwide Network
HMS has been highly effective in this role thanks to its nationwide network of clinical experts — surveyors, RNs, social workers and other healthcare professionals — deployable in every state and territory in the U.S. In addition, we have:
- Knowledge of data sources and program documentation requirements at a high level for BPCI Advanced, including ad-hoc patient care concerns related to model activity, adherence to Medicare payment policy waiver requirements, and enhanced understanding of unintended consequences to patient quality of care due to model participation.
- Effective records management and communication processes centered on HMS’s 256-bit SSL document portal.
- Knowledge of BPCI Advanced model participant care redesign planning and CEHRT capabilities. (CEHRT is a health IT product that has successfully passed testing on specific standards and criteria selected by the Centers for Medicare and Medicaid Services (CMS) for use in specific programs. CEHRT can be achieved through use of a single system or a combination of modules that can be used together.)
To date, HMS’ reviewers have participated in numerous compliance reviews/site visits and conducted more than 50 medical record reviews for compliance with Medicare Payment Policy Waiver Requirements and other program participation requirements.