CMS Creates New Episode Payment Models

AHLA The RAP Sheet, Volume 20, Issue 2, June 2017

Authored Article


On January 3, 2017, the Centers for Medicare & Medicaid Services (CMS) published a final rule implementing new episode payment models (EPMs) covering acute myocardial infarction (AMI), coronary artery bypass graft (CABG), and surgical hip/femur fractures (SHFFT) (the Final Rule).1 The Final Rule represents CMS’ further exercise of its authority under the Affordable Care Act (ACA) to develop new payment and service delivery models and demonstration projects. The models will be mandatory for acute care hospitals in certain designated Metropolitan Statistical Areas (MSAs). CMS will perform retrospective reconciliations comparing total Medicare Part A and Part B reimbursement to quality adjusted targets for defined episodes of care. Acute care hospitals will bear both upside risk and downside risk for a portion of the amounts determined pursuant to the reconciliation process.

The complete article first appeared in AHLA The Rap Sheet, Volume 20, Issue 2 in June 2017.