Key BPCI terms that will help you understand how Signature Care Management can help your business streamline patient care.
Accountable Care Organization (ACO):
Groups of doctors, hospitals, and other health care providers who provide care to Medicare patients.
Activities of Daily Living (ADLs):
Benchmarks providers use to determine the level of patient care needed (ex., can they clean their own house, take care of themselves, etc.).
Acute Care Hospitals (ACH):
Patient receives active but short term treatment for severe injury, episode of illness, or recovery from surgery.
Affordable Care Act (ACA):
Comprehensive healthcare reform law enacted in March 2010. Also known as Obamacare.
Alternative Payment Model (APM):
A payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
Ambulatory Surgical Centers (ASC):
Outpatient surgery centers.
Awardee Convener Bundled Payment Identification (Awardee BPID):
Identification number assigned to each practice participating in BPCI Advanced.
Awardee Convener:
Responsible for the financial risk of their own bundled payment patients and the bundled payment patients of their partners, regardless of where the patients receive care.
Awardees:
Medicare providers that bear risk for episodes they initiate.
Beneficiary Incentive Waiver List (BIL):
Allows an EI to provide a service or product to a beneficiary that is related to the episode but not typically covered by Medicare. There must be a reasonable connection between the service or product and the beneficiary’s medical care and the incentive must advance the beneficiary’s clinical goal.
Beneficiary Notification Letter (BNL):
Letter provided to each patient, by each practice, informing them that they are participating in BPCI Advanced.
Biopsychosocial care:
A method for addressing the medical, psychological, and social aspects of a patient's care.
Bundle:
The services provided under the episode of care.
Care Plan (CP):
The process for setting and monitoring specific patient goals while in the program.
CareMOSAIC (MOSAIC):
Our internally developed data management and Care Management system.
Case Manager (CM):
Nurse Case Manager in the office of a PGP, works directly with patients.
Center for Medicare and Medicaid Innovation (CMMI):
A division of CMS, piloting initiatives developed through the ACA.
Centers for Medicare and Medicaid Services (CMS):
Governmental agency overseeing Medicare and Medicaid.
Clinical Threshold:
Health indicators that optimize patients (ex., BMI or body mass index for obesity (greater than 40); infection risk factors; smoking cessation program; risk assessment tools for readmission, etc.). Also known as a "hard stop".
Comorbid Condition (CC):
One or more diseases or disorders occurring together.
Comprehensive Care for Joint Replacement (CJR):
A CMS mandatory value-based model, that encompasses all hospitals in 34 randomly selected markets and voluntary in another 33 for hip & knee replacements and nearly all associated care for 90 days following discharge. The model aims to boost care coordination between hospitals, skilled nursing facilities, rehabilitation centers, and home health agencies during joint replacement surgeries.
Convener:
Helps facilitate participation in the BPCI Advanced program by providing services such as data analytics and CMS compliance. There are two types: Facilitating and Awardee.
Corrective Action Plan (CAP):
Defined goals a group needs to achieve in order to stay in BPCI Advanced.
Critical Access Hospital (CAH):
A designation given to certain rural hospitals by CMS. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. This type of hospital is a more expensive alternative to SNF, particularly in rural areas.
Current Procedural Terminology code (CPT):
Billing codes used by physician groups.
Deep Vein Thrombosis (DVT):
Blood clot, usually in the leg/extremity.
Diagnostic Related Grouping (DRG):
Billing codes used by hospitals to classify hospital cases into 1 of 500 predetermined groups. The DRG number code specifies a group of related health care costs. In some instances the DRG code may change by severity of risk.
Discount:
Medicare takes a percentage of the cost of each episode occurrence. This is also phrased as providers offering Medicare a discount in exchange for participating in the BPCI Advanced program.
Durable Medical Equipment (DME):
Necessary medical equipment that the doctor prescribes for use in a patient’s home (ex., canes, hospital beds, oxygen equipment, crutches, walkers, commode chairs, etc.).
Electronic Medical Record (EMR):
Electronic patient chart at the PGP or Acute Care Hospital.
Episode:
The condition or reason for initiating treatment (ex., congestive heart failure, total knee replacement, etc.).
Episode Anchor (Anchor):
Acute care hospital admission that initiates an MS-DRG/HCPCS in the BPCI Advanced program.
Episode Initiator (EI):
The physician group that manages the actual care of the patient. An episode initiator can be a physician group practice or an acute care hospital.
Exclusion Lists (EL):
Items that are not included in the bundle.
Facilitator Convener:
Only responsible for the risk of their partners and their bundled payment patients.
Federally Qualified Health Center (FQHC):
Community-based health care providers.
Fee for Service (FFS):
Payment for services delivered to a patient, charging the patient at each care encounter.
Gainshare:
The concept that PGPs can receive savings gained from reducing the cost of an episode.
Gainshare screening list:
Lists physicians participating in the BPCI Advanced program and is sent to CMS by the Convener.
Health Insurance Portability and Accountability Act (HIPAA):
Legislation that ensures data privacy and security to safeguard medical information.
Healthcare Effectiveness Data and Information Set (HEDIS):
A tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.
Hemiarthroplasty (Hemi):
Trauma procedure (ex., hip fracture surgery like DRG 481 hip and femur procedures).
History and Physical (H&P):
The initial clinical evaluation and examination of the patient.
Home Care (HC):
Medical Care provided in the home that is not covered by major insurers, including things like bath aide and chore worker services.
Home Health (HH):
Medical care provided in the home by a medical professional and are billable services.
In-Patient Prospective Payment System (IPPS):
A system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Under the IPPS, each case is categorized into a DRG. Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.
In-Patient Rehabilitation Facility (IRF):
Facility that provides a higher level of medical care than what is needed in a SNF. Commonly referred to as Acute Rehab. Patient must need more than one modality of therapy and be able to tolerate 3 hours of therapy daily.
Internal Cost Savings (ICS):
Savings generated by the total episode spend compared to the target price.
Joinder agreement:
Puts physicians on the gainshare screening list to receive any cost savings achieved in the BPCI program. Physicians need to be on this list in order to be paid.
Key Performance Indicator (KPI):
A measurable value that demonstrates how effectively a PGP is performing (ex., readmission rates, SNF utilization).
Length of Service (LOS):
The amount of time a patient receives services from an entity such as HH.
Length of Stay (LOS):
The amount of time a patient is in a location like SNF. Usually the first day is counted, but not the day of discharge.
Letter of Credit (LOC):
How much financial risk an EI sustains before Signature Care Management becomes responsible for losses is provided to Signature Care Management in a Letter of Credit by a lending institution in the Practice’s name.
Long-Term Acute Care Hospitals (LTCHs or LTAC):
Specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return
Low Utilization Payment Adjustment (LUPA):
Episodes considered to be "low utilization" or not utilizing much of a health facility's resources (ex., if home health has a standard of 4 visits for care and patient stays for less than 4 visits, then the hospital that sent the patient to the home health facility would receive the payment, not the home health facility. This would also reduce the DRG by about $2,000).
Lower Extremity Joint Replacement (LEJR):
Lower extremity joint replacement.
Major Comorbid Conditions (MCC):
Major comorbid conditions, used in development of DRGs and affect coding in the inpatient setting.
Managed Care Organization (MCO):
Insurance companies.
Medical Cost Ratio (MCR):
Measures medical costs as a percentage of premium revenues.
Medicare Access and CHIP Reauthorization Act (MACRA):
A law that requires the implementation of the Quality Payment Program.
Merit-based Incentive Payment System (MIPS):
A quality reporting program component, allowing participants to earn a performance-based payment adjustment.
Motivational Interviewing (MI):
Motivational interviewing is a directive, client-centered counseling/interviewing style for eliciting behavior change by helping individuals explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed.
Myocardial Infarction (MI):
Heart attack.
National Provider Identifier (NPI):
A unique identification number for healthcare providers.
Net Payment Reconciliation Amount (NPRA):
Performance period target price - actual cost of episodes performed, adjusted for QPTs and including true-ups from previous performance periods.
Outlier cases:
A case in which something that occurred that was not expected. For example: a patient was fine when entering the hospital for surgery but had a complication which resulted in a higher overall cost for the case.
Passive Range of Motion (PROM):
How far a limb can move by someone else moving it.
Patient (Pt):
Patient Reported Outcome Measurements (PROM):
Assessments that attempt to capture whether the services provided actually improved patients' health and sense of well-being, from the point of view of the patient, (ex., PROMIS survey).
Per Member Per Month (PMPM):
A type of fee structure for a contract with managed care.
Physical Therapy (PT):
Physician Champion:
The physician in the PGP that is most likely to be the change agent, motivating the other physicians and staff regarding necessary changes related to value-based care.
Physician Group Practice (PGP):
Physician Quality Reporting System (PQRS):
A quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. 2016 was the last program year for PQRS. MIPS has replaced PQRS.
Post Acute Care (PAC):
Care provided after the patient is discharged from the hospital. Typically, "PAC provider" is a general term encompassing SNF, HH, PT, etc.
Prospective Payment System (PPS):
System of bundles with a pre-determined payment made for the bundle of services to be provided, paid prior to the actual episode.
Provider Enrollment, Chain and Ownership System (PECOS):
A Medicare provider online enrollment system.
Quality Payment Program:
The overarching term, for providers participating in Medicare Part B, that encompasses MIPS and APMs.
Retrospective payment bundling:
Payments are made at the usual fee-for-service rates (actual cost) then aggregated and compared to the target price.
Skilled Nursing Facility (SNF):
Facility that provides nursing care for a limited time period.
Star ratings:
Ratings provided by Medicare based on quality and performance.
Swing bed:
Patient beds in certain small, rural hospitals that enter into a swing bed agreement, under which the hospital can use its beds, as needed, to provide either acute or SNF care. As defined in the regulations, a swing bed hospital is a hospital or critical access hospital (CAH) participating in Medicare that has CMS approval to provide post-hospital SNF care and meets certain requirements. Medicare Part A (the hospital insurance program) covers post-hospital extended care services furnished in a swing bed hospital. Swing beds typically cost more per day than a traditional SNF bed.
Target price:
This is based on the discount and historical cost for the episode.
Tax Identification Number (TIN):
Identification number assigned to each practice participating in BPCI.
Telehealth:
Healthcare provided over the phone or video chat.
Total Joint Replacement (TJR):
Surgical replacement of damaged joint.
Total Knee Arthroplasty (TKA):
Surgical replacement of damaged knee joint.
True-up:
Residual payments from participation in previous periods of BPCI Advanced. A single episode may have 3 true-ups.
UB-04 Form:
The hospital uses this form for billing claims sent to CMS for DRG payments. If there is an incorrect DRG, the hospital has to re-submit the bill on UB-04 form since we can not appeal to CMS. We can then direct the PGP to the hospital to see if they can receive a copy of the form to then dispute with CMS.
Unilateral (Uni):
Surgical replacement of only one side of a joint (ex., removing part of a bone rather than the whole bone).
Utilization Review (UR):
The process used to review a patient’s medical condition and treatment plan to determine if it is medically necessary.
Waiver:
Non-medical services that can be provided to patients to increase the likelihood of reduced episode cost and improved outcomes. It does not affect the bundle but, affects the physician’s group business. Most commonly used waivers include: transportation and home health aides.