BPCI Data: Reconciliation

As a participant, the most important moment in the BPCI program is when reconciliation happens. Although not set in stone, this is the crucial moment when you know whether you performed above or below expectations set by CMS. If data did not matter until now (it really should), reconciliation is all about it. CMS provides all the information to confront with your own data and if problems arise, you can dispute. But this will delay the potential revenues CMS might send over so you'd better be prepared and have a plan of action when facing some (or all) of the following situations.

Beneficiary coverage

Typically there's a quarter lag of beneficiary coverage. So when comes reconciliation, it's very likely that the last month or so in episodes have no coverage information. According to specifications, only episodes with full coverage should be taken into account, but since there's a known lag, some lenience has been added in practice. The coverage is assumed to remain the same for the months where coverage information is lacking, and if it turns out to be wrong, CMS will address that in the next reconciliation (true-up).

You may be getting a financial reward this time around, but if coverage actually changed (terminated), then you may have to return that reward when next reconciliation comes around.

Trumped

With over 1,500 participants, it's very likely you're not the only one in the BPCI program. And if you're a Model 3, chances are you might get trumped by a Model 2 (or Model 4) provider upstream. You can read more about precedence rules and other gory details in our post on Episode Definition.

This should however not be considered a loss but an opportunity to become a preferred provider for a BPCI participant upstream.

Readmissions

Readmissions are based on basically two pieces of data: MS-DRG coding and your bundle selection. If you're in the middle of an episode and your patient was readmitted, then one of three things (disregarding trumping) can happen:

  1. If the readmission is about a new bundle (according to its MS-DRG) that you opted for, then a new episode is created and the earlier one is discarded.
  2. However, if you did NOT select that bundle, then that readmission is excluded from your costs and episode just goes on.
  3. If the readmission is considered an included readmission (based on rules defined by CMS), then the current episode goes on and the costs of the readmission are counted towards the episode total costs.

One thing that might surprise you is readmission rules for MS-DRG 469 and 470 (Major Joint Replacement). Both exclude themselves, which means if you have a selective surgery for either twice within your bundle period length, be aware that the episode from the first surgery will be discarded and only the second surgery and its episode will be kept.

CMS provides a list of MS-DRG exclusions that they update from time to time (without much notice). So it's good to keep an eye on it and understand the consequences of their coding and any changes that might occur.

Claims

If you've been following the data that CMS makes available month to month, it might come as a surprise to see some drastic changes at the claim level during reconciliation. Some claims might appear that were never there before. Some claims might just disappear. And for those claims still present in the data, payment amounts might have changed. And we've seen claims that actually do not pertain to you or your patient (which you should definitely dispute). So it's safe to say you should always take any reports based on monthly files with a grain of salt as numbers provided during reconciliation might differ from earlier data, even those that came out two weeks ago or even less.

Archway Health has helped many conveners throughout the BPCI process and especially during reconciliation. We want to be as helpful and efficient  as possible for ourself (being an Awardee Convener) and for our customers. Archway Health provides the tools to estimate your performance before reconciliation and make sure your current patients are on track with Archway Carelink.