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ABCS RCM provides skilled medical billing services for cardiologists. Due to this fact, we often monitor the CMS for coding and payment updates in the field of cardiology. CMS released a rule in late 2016 that finalized a mandatory bundled payment program for heart attacks and bypass surgeries. This ruling also expanding the existing Comprehensive Care for Joint Replacement (CJR) model. This meant that some acute care hospitals will be held accountable for the cost and quality of care delivered to their patients.

Basically, the new CJR model requires that participating hospitals be held financially responsible for the quality and cost of a CJR episode of care. Naturally, some incentives are also included in order to reward health systems, doctors, and post-acute care providers who demonstrate a better level of coordination of care for their patients. This new bundled payment program would include heart attack, coronary bypass and surgical hip and femur fracture patients; and start with the initial hospitalization and extending 90 days after discharge. In addition, the new rule would expand the existing CJR model to include additional surgical treatments for hip and femur fractures.

Individual hospitals, after review, receive episode-based payments from the program. As a reward, hospitals that spend less than the target price for the episode of care, while maintaining or exceeding quality standards, are allowed to keep any excess revenue. As a punishment, hospitals that exceed the total cost of the target price, are required to repay Medicare. In these scenarios, the CMS is employing a carrot and stick strategy.

This accountability model has not gone unnoticed by healthcare organizations. For example, the American Hospital Association (AHA) has stated that some parts of the CJR bundle payment program are beneficial, particularly the allowed flexibility with MACRA participation. Yet, the AHA is concerned about how quickly the new rule was implemented. They argue that these new bundled payment models for cardiac care are overwhelming many health systems and cardiologists. There have been too many changes in a relatively short amount of time.

So what should hospital administrators and cardiologist do? Sometimes simply waiting is the best solution.

In August of 2017, the Centers for Medicare and Medicaid Services proposed canceling the new cardiac and expanded joint replacement bundled payment initiative. The Office of Management and Budget announced that they would cancel the mandatory bundled payment programs for heart attacks and bypass surgeries as well as the expansion of the existing Comprehensive Care for Joint Replacement model to include surgical treatments for hip and femur fractures. Interestingly, these bundled payment initiatives have already been postponed twice. Cardiologist and other cardiac care professionals are watching the CMS closely. It is still unclear as to whether another bundled payment rule will be proposed.

Contact us at ABCS RCM for additional questions about the bundled payment initiative or other general medical reimbursement questions.

CMS, Cardiology, Cardiac Bundle Payment

Additional information:  Cancellation of Advancing Care Coordination through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P)

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