As the fee-for-service environment becomes outdated, medical billing companies are well aware that the future of revenue cycle management in healthcare could be influenced by alternative payment models such as bundled payments. Under the bundled payment model, healthcare providers and facilities will be paid a single payment for all the services performed to treat a patient undergoing a specific episode of care. An “episode of care” is the care delivery process for a certain condition or care provided within a defined period of time. The aim of this model is to enhance improve care quality and coordination, while also decreasing costs for patients.

In December 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule detailing bundled payment models for cardiac services with the goal to reduce costs for patients with heart attack or who undergo bypass surgery. In March 2017, CMS announced it will delay from July 1 to October 1, two bundled payment programs for heart attack treatment and bypass surgery billed through Medicare. The delay will give CMS more time to review the programs and also give providers more time to prepare for the payment changes under the models.

The proposed mandatory payment models-the Acute Myocardial Infarction (AMI) Model and the Coronary Artery Bypass Graft (CABG) Model-are retrospective, 90-day bundles in which hospitals will need to reduce their episodic costs below a target quality-adjusted cost threshold lower than the historical average. The payment models are aimed at rewarding hospitals for high quality coordinated care that will avoid complications, prevent hospital readmissions and speed recovery. They are set to take effect in 98 metropolitan areas.

Bundling Payment ProgramsEach year, CMS will fix the target prices for different episodes of care based on a combination of regional historical data and hospital-specific data on total costs for Medicare fee-for-service patients admitted for heart attack and bypass surgery – from hospitalization through 90-days post-discharge. The bundled payment model for cardiac services would works as follows:

  • The hospital admitting the patient for heart attack or bypass graft surgery would be responsible for the cost and quality of the care provided to Medicare fee-for-service beneficiaries during their inpatient stay and 90 days post-discharge.
  • Target prices will be adjusted based on the complexity of treating a heart attack or performing bypass surgery
  • Hospitals would be paid a fixed target price per episode and those that deliver higher-quality care will get a higher target price.
  • At the end of the model year, the actual spending for the episode of care will be compared to the targeted price which is an indication of the quality of care outcomes of the hospital.
  • Hospitals and physicians that meet or exceed quality standards while providing the necessary care for less than the quality-adjusted target price, will share in all or a portion of the savings
  • Hospitals that do not meet the above-mentioned standards would be required to repay Medicare the difference, and will thereby lose revenue.

To succeed in the bundled payments model, all the healthcare organizations involved in the episode of care should work together to provide quality care and reduce costs. They should educate themselves and their teams on the new payment models. As diagnosis-related groups (DRGs) drive the conditions to bundle, accurate DRG assignment and DRG coding will be crucial. Electronic medical records must have accurate data on patient diagnoses and co-morbidities; service dates, types, and cost, and patient and provider identifiers. Reliable medical coding services are necessary to avoid ICD-10 coding errors. As the Alabama Association for Health Information Management (AAHIM) points out, medical coding companies can also work as data analysts and help providers evaluate patient care processes and information flow.