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Medicare releases guidelines for model 4 bundled payments for care improvement

The Centers for Medicare & Medicaid Services (CMS) is conducting a pilot program to test bundling payment for services that patients receive during a single episode of care, such as heart bypass surgery or a hip replacement. The Bundled Payments for Care Improvement (BPCI) program seeks to encourage doctors, hospitals, and other health care providers to work together to better coordinate care for patients.

CMS recently released guidelines for providers participating in its model 4 BPCI pilot program. The episode of care is defined as the acute care hospital stay and includes inpatient hospital services, Part B services furnished during the hospitalization, and hospital and Part B services for related readmissions.

Hospitals that participate in the model 4 initiative will receive a prospectively established bundled payment for agreed upon Medicare severity diagnosis related groups (MS-DRGs). This payment will include both the DRG payment for the hospital and a fixed amount for the Part B services anticipated to be rendered during the admission.

MLN Matters article MM8070, on which this summary is based, summarizes Medicare’s implementation of the model 4 initiative. The article addresses issues related to readmissions, claims crossover, remittance advice, claims submission, and beneficiary eligibility. 

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