On January 9th, 2018 the Centers for Medicare and Medicaid released their next gen Bundled Payment Care Improvement (BPCI) program, BPCI Advanced.  This new program builds upon lessons learned from current and previous models.  At Royal Jay we enjoy rolling up our sleeves and learning all things CMS, but understand its not everyone’s cup of tea; so we’ve taken the liberty of summarizing what we found and thought we’d share with you.


Things you should know:

  • It’s a voluntary program
  • It qualifies as an Advanced Alternative Payment Model (AAPM)
  • It is a retrospective payment model and target prices will be set based on historical data
  • Initial applications due March 12th, 2018
  • Set to begin October 1st, 2018 and will run for 5 years
  • Participants can choose from 29 of the existing inpatient episodes and 3 new outpatient episodes  
  • Preliminary target prices will be provided in advance of the performance year, but after the initial 2018 application deadline
  • Reimbursement will be tied to seven quality measures, 2 of which are required regardless of episode, and five applicable only to certain bundles.  
  • Participants are referred to as Episode Initiators (EI’s). EI’s are categorized into 2 groups, which CMS defines below
    • Convener participant: Brings together a group of episode initiators, facilitates coordination and bears and apportions risk among the participants.   Eligible convener participants include: Medicare-enrolled providers or suppliers, eligible entities not enrolled in Medicare, Acute Care Hospitals (ACHs), Physician Group Practices (PGPs)
    • Non-convener participant:  PGPs and ACHs.  These are the only provider types allowed to pursue this model by themselves versus part of larger group



Big changes between BPCI models:

  • BPCI Advanced meets Advanced APM Criteria, BPCI does not
  • 32 total episodes in BPCI Advanced, compared to 48 total episodes in BPCI
  • BPCI Advanced includes Hospice as a covered services where BPCI did not
  • SNFs, LTCHs, IRFs, HHA are no longer considered Episode Initiators under BPCI Advanced
  • Payment is tied to quality measures under BPCI Advanced, where they had not been previously under BPCI
  • Reconciliation occurs Semi-Annually under BPCI Advanced, vs Quarterly under BPCI
  • 3 Day Stay SNF Rule, Telehealth, Post-Discharge Home Visit, Beneficiary Incentives Waivers are all now applicable under BPCI Advanced



Where to find more information:

CMS has published helpful resources to assist healthcare organizations determine if they would benefit from participating in the BPCI Advanced Model.  See BPCI Advanced Fact Sheet for more resources, like the ones below

  • Participant eligibility for non-conveners and conveners
  • Model timeline and roadmap
  • Definition of clinical episodes
  • List of quality measures
  • Details on application process
  • Application materials



Helpful tips when deciding to participate in BPCI Advanced:

  • Request your data from CMS.  CMS will provide you with data used to calculate preliminary target prices and your historical claims
  • Assess the risk and rewards.  Use data to ascertain where there is high volume, associated risks, potential rewards and identify clear areas of operational improvement that can be made across the network or facility.
  • Organizational buy-in.  Take advantage of CMS’s open door forum on this model, scheduled for Tuesday, January 30th, 2018 from 12:00 PM to 1:00 PM EST.  The link to register can be found here.



Author: Natoshia Erickson

Senior Manager of Solution Delivery