Edifecs Population Payment Management Episodes of Care Module combines episode analytics with management and workflow tools for episode bundling and gainsharing administration to help IDNs, hospitals, physicians and post-acute care providers maximize revenue under bundled payment, including the common cardiac and orthopaedic episodes, developed by nationally recognized entities, including the CMS CJR payment model.
Automation, Scalability & Transparency
Automation makes episode payments effective, scalable and cost-efficient. Edifecs Population Payment Management Episodes for Care Module provides a comprehensive software module to automate the complete episode lifecycle, from design to episode management to audit and reconciliation with external third party payers. The module provides analytics and workflow tools for administering and scaling gainsharing with episode providers. Performance dashboards and management reports provide visibility to episode and gainsharing performance to all collaborating providers in real time.
Episode Payment Solution for CJR
Edifecs Population Payment Management Episodes of Care Module automates the complete episode management lifecycle, from design to management to audit and reconciliation with external third party payers. It evaluates historical and current performance of providers to identify preferred episode collaborators. IDNs, hospitals, physicians and post-acute care providers can leverage the module to manage alternate episode-based payment models such as Comprehensive Care for Joint Replacement, bundled payments including common cardiac, oncology care etc.
CMS CJR collectively anchors a quarter of all lower extremity joint replacement episodes nationwide. While hospitals bear the ultimate financial responsibility under CJR, to be successful, you must cultivate relationships with other providers, orthopedic surgeons, post-acute, and primary care collaborators to align around critical price targets and quality metrics. The ability to design and administer gainsharing programs with near real-time performance visibility shared across all collaborators is the key to success.
Population Payment Management Episodes of Care module for CJR combines custom CMS analytics essential for strategic care redesign, preferred provider selection and gainsharing program design. Interactive dashboards, reports and workflow enable episode providers to understand care decision impacts while gaining insight into the current performance of signed contracts.
Target - CJR Analytics and Assessment
Intake and validate historical CMS episode payment data
Perform episode volume analysis by DRG and LEJR procedure
Analyze and compare hospital to regional episode costs
Perform trended and annual inpatient and post-acute provider utilization and cost analysis
Assess quality outcomes and isolate factors driving quality variations
Leverage preconfigured CJR episode design template reflecting the final CMS rule
Implement CJR episode initiation, inclusion and exclusion criteria
Establish target episode price and gainsharing provisions
Apply CJR quality metrics and composite scoring rules to CMS and provider gainsharing
Administer – Monitor and Manage Active Episodes
Ingest and process episode payments from all providers and suppliers
Reconcile and identify missing or incomplete episode costs
Compare active episode costs and quality to target price and KPIs
Alert and notify episode providers about performance and KPI status
Audit and Reconciliation
Produce Medicare Episode and PAC reports
Share reports with collaborating episode providers and suppliers via a reports portal
Reconcile and audit episode-related costs with CMS payments
Prepare discrepancies and appeals in advance of final CMS year-end report