Participant Profiles (PP) - Submitted once per Model Year, 60 days before the start of the Model Year
In this document, Participants identify which Episode Initiators and Clinical Episodes they want to have in “Active” status. Selections made in the Participant Profile (PP) are binding to the Participant, per the terms of the Participation Agreement, until the start of the next Model Year.
Care Redesign Plan (CRP) - Submitted once per Model Year, 30 days before the start of the Model Year
In this document, the Participant identifies the basic organizational infrastructure and processes needed to operationalize BPCI Advanced. Care Redesign Interventions refer to the planned interventions and changes to the Participant’s current healthcare delivery system.
Financial Arrangement List (FAL) – Submitted 30 days before the start of every quarter
In this document, the Participant will list each NPRA Sharing Partner, NPRA Sharing Group Practice Practitioner, and BPCI Advanced Entity, as defined in the Participation Agreement.
Quality Payment Program (QPP) List – Submitted 30 days before the start of every quarter
This document will be used by CMS to create a quarterly BPCI Advanced QPP Report that the Quality Payment Program team will use to make the Qualifying APM Participant (QP) determinations for eligible clinicians identified as Participating Practitioners in the Model.
The BPCI Advanced Model uses a retrospective bundled payment approach. Specifically, under BPCI Advanced, CMS may make payments to Model Participants or Model Participants may owe a payment to CMS after CMS reconciles all non-excluded Medicare FFS expenditures for a Clinical Episode against a Target Price for that Clinical Episode. The Target Price calculations, Reconciliation calculations, and attribution of Clinical Episodes to Participants will each occur at the Episode Initiator (EI) level.
Clinical Episode Construction Specifications
The specifications are divided into the 6 sections that correspond to detailed descriptions of the sequential stages of the Clinical Episode construction process. The main document contains specifications for constructing Clinical Episodes in both the baseline period and Performance Periods of a Model Year. The Appendix maps MS-DRG changes from year to year as documented in the CMS annual transmittals\IPPS Final Rules.
In BPCI Advanced, Clinical Episodes are attributed at the Episode Initiator (EI) level. The hierarchy for attribution of a Clinical Episode among different types of EIs is as follows, in descending order of precedence: (1) the PGP that submits a claim that includes the National Provider Identifier (NPI) for the attending physician; (2) the PGP that submits a claim that includes the NPI of the operating physician; and (3) the ACH where the services that triggered the Clinical Episode were furnished. There are no time-based precedence rules in BPCI Advanced.
The Centers for Medicare & Medicaid Services (CMS) will calculate a Benchmark Price Using claims based historical data and risk adjustment models to account for variation in the Clinical Episode’s standardized amounts. The baseline period for Model Years 1&2 Benchmark Prices contained data from potential Clinical Episodes that would have been attributed from January 1, 2013 through December 31, 2016. For Model Year 3 (2020), the baseline period will contain data from potential Clinical Episodes that would have been attributed from October 1, 2014 through September 30, 2018.
A 3% discount will be applied to the Benchmark Price to calculate the Target Price for each Clinical Episode category for each Episode Initiator.
Target Prices for hospitals are constructed to account for multiple aspects of the Clinical Episode:
- The hospital’s own past performance
- The characteristics of patients treated during the Clinical Episode(s),
- The hospital's peer group characteristics.
- The hospital’s peer group trends.
For Model Year 1&2, Participants received preliminary Target Prices in the summer of 2018, which were subsequently updated to account for new payment rates. CMS will rebase and provide new Preliminary Target Prices for Model Year 3 (January 1, 2020 – December 31, 2020). When CMS makes changes to the IPPS & OPPS payment rates paid under the Medicare Fee for Service (FFS) system, CMS will update the preliminary Target Prices to account for the changes, but will not rebase the preliminary Target Prices with new baseline period data until the next Model Year.
After each Performance Period (Jan-June & July-Dec), during the Reconciliation process, CMS will compare the aggregate Medicare FFS expenditures for all items and services included in a Clinical Episode against the Target Price for that Clinical Episode to determine whether the Participant is eligible to receive a payment from CMS, or is required to pay a Repayment Amount to CMS. Participants can expect their first Reconciliation results for Performance Periods 1&2 in the fall of 2019. Additionally, each Performance Period will be subject to at least two (2) true-ups with additional claims run-out. For instance, for episodes ending between July 1, 2019 and December 31, 2019, the reconciliation will occur in the spring of 2020. Subsequent true-ups will occur in the fall of 2020 and spring of 2021, which will allow between 15 and 21 months of claims run-out, following the end of the Clinical Episode end dates.
CJR vs BPCI Advanced
A Comprehensive Care for Joint Replacement (CJR) Participant Hospital in one of the 34 mandatory Metropolitan Statistical Areas (MSAs) will have has precedence on the MJRLE Clinical Episode over a PGP in BPCI Advanced. This means that the Clinical Episode will be attributed to the CJR Participant Hospital and not the PGP participating in BPCI Advanced. PGPs participating in BPCI Advanced will have precedence over a CJR Participant Hospital that is also participating in BPCI Advanced for all other Clinical Episodes. A CJR hospital is able to participate in BPCI Advanced for Clinical Episodes other than MJRLE (MS-DRGs 469 and 470), including other orthopedic-related episodes.
Portals for Current Participants
Users need to be authorized. Each Portal has different process for granting access to users.
The Participant Portal is an online platform that allows Participants to: access and review organizational data, download templates and submit deliverables, verify Clinical Episode selection and update Points of Contact (POCs). The Announcements section is an archive of mass email communications previously sent by the BPCI Advanced Team, as well as Model reference materials.
The Data Portal is the platform via which CMS will deliver different types of files: preliminary Target Prices, baseline data, monthly claims data and semi-annual Reconciliation results.
Participants who have completed a Data Request and Authorization (DRA) form will designate two Data Points of Contact which once authorized will have the ability to approve additional users. Data POCs are not the same as Participants POCs. They may, and could, be the same person but are not necessarily the same individual. They have different roles and authorization for access to each Portal is different.
CMMI Connect is the Innovation Center’s online collaboration and knowledge management tool used to facilitate peer-to-peer learning. The platform was designed especially for Innovation Center model participants to streamline collaboration and it allows them to work together on shared interests and goals regardless of location.
The BPCI Advanced Connect Library contains two groups:
- The General Bundled Payment Resources contains information, reports, and tools related to bundled payment models similar to BPCI Advanced that have been reported as useful by Participants in many bundled models.
- The BPCI Advanced Library houses information specific to the BPCI Advanced Model. Here you can find monthly newsletters, past webinars, Fact Sheets, and other Model-related information.
How to Contact the BPCI Advanced Team
If you have questions regarding the Model, you can contact the BPCI Advanced team by emailing BPCIAdvanced@cms.hhs.gov.
Additional Participant Information
- BPCI Advanced Participants - MY2 (XLS)
- BPCI Advanced Episode Initiators and Clinical Episode Selections - MY2 (XLS)
- Model Overview Fact Sheet - MY3 (PDF)
- Pricing Methodology FAQs (PDF)
- SNF Waiver List - Q3 2019 (XLS)
- Webinar: Model Overview MY3 (2019): Audio (MP4) | Slides (PDF) | Transcript (PDF)
- Webcast: Model Overview MY3 - Audio (MP4) | Slides (PDF) | Transcript (PDF)
- Claims Files Layout (XLS) (2019)
- Episode Definitions - MY1&2 (XLS)
- Episode Definitions - MY3 (XLS)
- Clinical Episode Construction Specifications - MY1&2 (PDF)
- Clinical Episode Construction Specifications - MY1&2 - Appendix A: MS-DRGs (PDF)
- Exclusions from Clinical Episodes (DRGs & HCPCSs codes) MY1&2 (XLS)
- Reconciliation Specifications - MY1&2 (PDF)
- Target Price Specifications - MY1&2 (PDF)
- Target Price Specifications - MY3 (PDF)
- Webinar: Pricing Methodology Technical Review (2018) - Audio (MP4) | Slides (PDF) | Transcript (PDF) | Data Workbook Example (XLS)
Please visit the Additional Resources section on the General Information page for additional materials about the Model.