Welcome to the HealthPRO Heritage Blog

January Advisor Newsletter

Attention: CMS has released updated quality measure star ratings for all LTC providers. The Nursing Home Compare site was updated January 24, 2018.

RCS-1: Get Ready, While We Watch & Wait

HealthPRO®/Heritage continues to lead the industry in preparation for RCS-1 as we prepare for a likely reimbursement system overhaul.

Based on the fact that CMS received a high volume of comments from industry stakeholders during the extended public comment period through August 2017, we expect there will be some changes to the Advance Notice Proposed Rulemaking (ANPRM) regarding the complete overhaul of PPS. We do know that payment reform is coming, and we must be prepared for a big change in our industry. We will stay close to the proposed changes to be released in April 2018. 

HealthPRO®/Heritage strategy is to watch, to wait and to BE PREPARED! The providers who come out on top will be the ones most well prepared to weather the transition, should the system change occur as scheduled on October 1, 2018.

Stay tuned: HealthPRO®/Heritage will report out following the proposed rule to be released in April 2018 with any potential changes.

Learn more about the HealthPRO®/Heritage strategy by viewing a recording of our RCS-1 Webinar (released Nov 2017)

More Bundled Payments Are Coming Fiscal Year 2019

The “next generation” of voluntary bundled payments is here! 

On January 9, CMS and Medicaid Innovation (Innovation Center) announced the launch of its new voluntary bundled payments initiative “Bundled Payment for Care Improvement (BPCI) Advanced.” 

Considered the “next generation” of the original BPCI initiative, this 2.0 version advances CMS’ agenda towards value based care, rewarding those providers who drive quality care (but at lower costs).

How is BCPI Advanced different from the first BPCI initiative? BPCI Advanced:

  1. Links quality with earning additional payment if all expenditures for a beneficiary’s episode of care are below a spending target
  2. Hosts a total of 32 clinical episodes, including 29 inpatient clinical episodes consisting of 105 Medicare Severity-Diagnosis Related Groups (MS-DRGs) and 3 outpatient clinical episode categories. Each identified by 30 Healthcare Common Procedure Coding System (HCPCS) codes versus the original BPCI with only 48 DRGs. We included a comprehensive list of the 32 clinical episodes at the end of the article.
  3. Features a single retrospective bundled payment and one risk track with a 90-day clinical episode duration
  4. Requires no SNF or Home Health Agency Episode Initiators – otherwise no BPCI Model 3s
  5. Semi-annual reconciliation (versus quarterly as with original BPCI)
  6. Includes hospice
  7. Remains voluntary, like the original, but unable to opt out of any clinical episodes for first 15 months

What should you know?

CMS is required to implement the Quality Payment Program (QPP) according to the Medicare Access and Chip Reauthorization Act (MACRA). This program changes the way physicians are paid by Medicare. QPP creates two tracks for physician payment:

  1. Merit-Based Incentive Payment System (MIPS) track
  2. Advanced APM track where providers take on financial risk to earn the Advanced APM incentive payment

What should you do next?

  1. ReDesign Care: Reduce Medicare expenditures within a defined budget while maintaining quality care. A strategy to consider: full implementation of HealthPRO®/Heritage’s “Safe Transitions Framework” to assure cost effective case management balanced with highest quality of care.
  2. Communicate and Support: Work closely with regional physicians groups, hospitals, etc. to understand their role in MACRA. For example, will they participate in MIPS track or the Advanced APM track? As a downstream provider, you will be required to coordinate collection/reporting on non-claims based measures as part of participation in this Model. 
  3. Review and Track Functional/Clinical Outcomes: Work with HealthPRO®/Heritage’s Clinical and Regional Teams to understand key levers for success. Our subject matter experts can offer “lessons learned” based on our national consulting/educating roles in the current healthcare environment. Make it a point to understand what clinical capabilities you currently have, and any clinical programs you need or are actively providing. What outcomes are you tracking and how do they stack up?

What is the timing on BCPI Advanced?

The Model Performance Period for BPCI Advanced starts on October 1, 2018 and runs through December 31, 2023. Open enrollment begins on January 11, 2018 and is open only until March 12, 2018.

Where does quality come in?

The “Required Measures List” is included here.  Be aware that this list may change and/or be updated annually. Claims-based measures highlighted below are to be collected by CMS directly, and will be required for those participating in the Model beginning October 1, 2018 for the first two years 2018 and 2019. The remainder of the measures will be collected beginning Year Three (2020). 

Each participant will need to coordinate with their downstream providers and suppliers to collect/report on all non-claims based quality measures. CMS will require these measures are reported no later than February 20th the year immediately following the model year in which the quality measures were applicable. All-cause Hospital Readmission Measure and Advanced Care Plan will be required for all clinical episodes and others will be required for certain clinical episodes.

Required Measures List – Quality Measure Name
Collected In Years One and Two (2018 & 2019) Collected in Year Three (2020)
Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268) CAHPS for Clinicians (NQF #0005)
All-cause Hospital Readmission Measure (NQF#1789) CAHPS for Hospitals (NQF #0006)
Advanced Care Plan (NQF #0326) CAHPS Home Health Care (NQF #0166)
Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550) Hypertension: Improvement in Blood Pressure (CMS #373)
Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558) Drug Regimen Review with Follow Up (CMS #2849)
Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881) Surgical Site Infection (SSI) (NQF #0299)
AHRQ Patient Safety Indicators (PSI) Unplanned Reoperation within the 30 Day Postoperative Period (CMS #1966)


29 Inpatient Clinical Episodes
Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis (New episode added to BPCI Advanced) Gastrointestinal obstruction
Acute myocardial infarction Hip & femur procedures except major joint
Back & neck except spinal fusion Lower extremity/humerus procedure except hip, foot, femur
Cardiac arrhythmia Major bowel procedure
Cardiac defibrillator Major joint replacement of the lower extremity
Cardiac valve Major joint replacement of the upper extremity
Cellulitis Pacemaker
Cervical spinal fusion Percutaneous coronary intervention
COPD, bronchitis, asthma Renal failure
Combined anterior posterior spinal fusion Sepsis
Congestive heart failure Simple pneumonia and respiratory infections
Coronary artery bypass graft Spinal fusion (non-cervical)
Double joint replacement of the lower extremity Stroke
Fractures of the femur and hip or pelvis Urinary tract infection
Gastrointestinal hemorrhage

3 Outpatient Clinical Episodes
Percutaneous Coronary Intervention (PCI) Cardiac Defibrillator Back & Neck, except Spinal Fusion


Home Health “Reality Check”

Effective January 13, 2018, new CoP changes went into full effect for the home health industry. At HealthPRO® Heritage at Home, we know change is never easy. As valuable strategic partners in the home health industry, we leverage our innovative resources and subject matter experts to assure successful execution and outcomes on behalf of the clients we serve.

We offer our clients the following guidance/perspective as it relates to our “New Reality:”

  • While agencies anxiously await the release of the final draft for interpretive guidelines, industry leaders do not expect a drastic difference from what was presented in the December 2017 interpretive guidelines draft. HealthPRO® Heritage at Home recommends that our clients look to the actual regulations rather than on the interpretive guidelines themselves for compliance guidance.
  • Every therapist must abide by the CoPs each and every time a patient is seen. Consistency will be key! It will be important for patients and their caregivers to be informed of therapy schedules, be provided medication schedules when appropriate, and to be informed of his/her rights.
  • A proactive approach to training/educating staff is imperative in our “New Reality.” HealthPRO® Heritage at Home recommends having a process in place to provide all staff members the opportunity to communicate questions to ensure full understanding of new rules and regulations.
  • HealthPRO® Heritage at Home has taken the following steps in response to these newest changes:
    • HHH “CoP Open Door Forum” webinar recorded and available upon request.
    • Our Quality Assurance and Compliance team presented CoP changes to our staff via recorded webinar and podcasts. All of our home health clinicians were required to attend.
    • Provided a comprehensive “Q & A” resource for our clinicians as a reference for new rules and regulations to help guide them through challenges they may face.
  • If not already in process, begin thinking about QAPI and Performance Improvement Plans (PIP) now. This is a great opportunity to partner with your therapy providers on pulling any data needed to analyze and to help assist with implantation of the PIPs.
  • Challenges have arisen with the new requirements regarding verbal orders. Open communication between agency, physicians, and therapy providers is key to working through these challenges and determining the best practices for the process behind obtaining verbal orders for each individual agency and physician.

We at HealthPRO® Heritage at Home welcome any questions or feedback on our new reality!

Questions about what you read or ready to partner with HealthPRO®/Heritage?

Contact us today!

Tags: CMS, HealthPRO/Heritage, senior living, Home Health, RCS-1, Nursing Home Compare Website, Bundled Payments, BCPI, Bundled Payment for Care Improvement Advanced