Blog, The Hospital Finance Podcast®

CJR Data Sharing And Payment Reconciliation [PODCAST]

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Hospital_Finance_Podcast smallIn this episode, Maria Miranda, Director of Reimbursement Services at BESLER Consulting reviews how data is shared and payments reconciled for the Medicare Comprehensive Care for Joint Replacement (CJR) bundled payment program.
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Michael Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast. Today, I’m joined by Maria Miranda who is Director of our Reimbursement Services team here at Besler Consulting. And as part of our CJR series looking at that bundled payment program, Maria today is going to be talking to us about the data sharing elements as well as how payments will be reconciled for hospitals in the program.

So, welcome, Maria. Thanks for being with us.

Maria: It’s great to be here Mike!

Mike: Maria, how can a hospital obtain their data?

Maria:  I’m sure that by now, most Hospitals in the CJR program have already requested their data in are in the midst of analyzing it. But if they haven’t, they can do so by emailing CMS at  They will need to include two points of contact and the Hospital’s CCN in the subject line.

Mike: Then how can the hospital review the Per Episode Payment Data?

Maria:  CMS issued a series of HIPAA-compliant Summary and Detail Claims relevant to CJR. The available files include claims detail on the anchor admission as well as all services delivered by post-acute providers in the 90 day period considered part of the CJR episode. The data was run based on admission dates from 2012-2014.

The hospital will also find a hospital specific summary file and a Regional file. The hospital can use these summary files to determine how they compare to the region by MS-DRG/Fracture Combination and by service type. There is also a file containing demographics on each beneficiary that includes such items as gender and age that can assist you in your analysis.

Mike: Okay. When will CMS make the data available to providers?

Maria: This baseline data is available now – It was made available back in March and April, however CMS updated the summary files and included a new file containing information that allows the provider to replicate their target prices. This new file was added under the “Pricing” sub-folder and includes the national growth factors, update factors, wage index and discount for each hospital for the first performance year. CMS also made corrections to the target prices originally posted. These new files were posted at the end of April and early May. So, even if a hospital downloaded their files in late March or early April, they need to go back in and check for new and updated files.

Mike: And how often will that data be available?

Maria: CMS will issue the data on a quarterly basis during each performance year. So, it’s very critical to keep checking your data as it gets uploaded.

Mike: So turning to the reconciliation portion of our discussion, can you explain for us how CMS will determine the Net Payment Reconciliation Amount for each organization?

Maria:  The Net Payment Reconciliation Amount or the NPRA is the sum of the amounts above or below the target price for each CJR episode in the performance period. If your hospital exceeds the target amount for cases as determined by CMS for that MS-DRG/Fracture Combination, then there is money owed back to CMS by the hospital. However, that payback amount is waved in this first performance period and capped at increasing percentages in future performance years. If the hospital comes in under the target amount for these CJR episodes, it can receive a reconciliation payment from CMS assuming that they also meet the program’s quality requirements as we discussed in a previous podcast recording.

Mike: And how will CMS reconcile the hospital’s potential payment or repayment amount?

Maria: Well, initially, CMS will run out the claims data starting in March of 2017 for the 1st performance period and issue the participating hospital a Reconciliation report. The report will include:

  • Information on the participating hospital’s composite quality score
  • The actual episode payments for the participating hospital
  • The NPRA
  • Whether the hospital is eligible for a reconciliation payment or must make a repayment
  • The reconciliation payment or repayment amount

One year later, they’ll do a final run-out for the same performance period. This allows for corrections and late filings, etc…

Starting with performance year 2, there will be an additional item included in the Reconciliation report that would appear just before the reconciliation payment or repayment amount is shown, which is:

  • The NPRA and subsequent reconciliation for the prior performance year, if applicable

It is important to note, that your reconciliation will be impacted by the change in target prices throughout the course of the program because these prices will be determined by utilizing a blend of both hospital-specific and regional spending amounts. In PY’s 1&2, the breakout is 2/3rds Hospital and 1/3rd Regional, that changes to 1/3rd Hospital and 2/3rds Regional in PY 3 and then 100% Regional for PY’s 4&5.

Mike: How will stop loss and stop gain percentages be applied?

Maria: There is no repayment in performance year 1 and the stop gain percentage is 5%. In PY 2, the stop-gain and stop-loss are both set at 5%. In PY 3, the stop-gain and stop-loss are both set at 10% and in PY’s 3&4, the stop-gain and stop-loss are both set at 20%.  As reflected in some of the tables that we published in our special report, you can see that rural referral centers, sole community hospitals, and Medicare-dependent hospitals have lower percentages established for stop-gain and stop-loss.

Mike:  And what if the post-acute care period exceeds 90 days?

Maria:  If the episodes, on average, are 30 days longer and the spending is greater than three (3) standard deviations above the regional average, then the reconciliation payment can be reduced or the repayment amount may increase by the amount that is over the three (3) standard deviations.

Mike: Got it! Maria, thanks so much for taking some time to explain data sharing and payment reconciliation under CJR.

Maria: Oh, you’re welcome. Thank you very much for having me, Mike.

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