7.1 Eligibility
7.1.1 Network hospitals that provide
childbirth services to TRICARE beneficiaries will be automatically considered
for Value, High Value, or High-Risk
Delivery incentive payments on a retroactive annual basis
if they elected to participate in the Leapfrog Group Hospital Survey,
and have provided applicable performance data to the Leapfrog Group
on their maternity quality metrics. Network hospitals that do not
report maternity care metrics in the Leapfrog Group Hospital Survey
and non-network hospitals are not eligible for P-BMP incentives.
Alternative forms of evidence for maternity care quality will not
be accepted for P-BMP pilot purposes or incentives (only official
Leapfrog data are accepted).
7.1.2 Network
hospitals that achieve
Value,
High Value,
or
High-Risk Delivery tier ratings will be awarded
a retroactive annual incentive payment (subject to the provisions
of the P-BMP pilot) based upon their performance rating, the volume
of TRICARE deliveries at each hospital during each incentive cycle,
and the total TRICARE allowable amount for these deliveries. The
rating in effect on August 1st each year will be used for incentive calculation
purposes; this rating shall be applied retroactively to TRICARE
deliveries during each incentive cycle as follows:
|
Incentive Cycle
|
Leapfrog Rating (as of date)
|
Date of
Service (Hospital Admission)
|
|
* Or last day of health care
delivery under the contract, whichever comes first.
|
|
1
|
August 1, 2019
|
Commencement of Phase II September
1, 2018 through December 31, 2018*
|
|
2
|
August 1, 2020
|
January 1, 2019 through December
31, 2019*
|
|
3
|
August 1, 2021
|
January 1, 2020 through December
31, 2020*
|
Note: Incentive cycles end on December
31st each year to allow time for claims processing to occur prior
to incentive calculations, which will commence on August 1st of
the following year.
7.1.3 P-BMP
incentive payments are not appealable; however, if hospitals identify
a suspected calculation error, they may provide written notification
of the suspected error (with substantiating documentation) to the attention
of the appropriate regional contractor within 180 calendar days
of the date of the incentive payment with the suspected error. The
contractor shall investigate the matter, and if it indicates that
a calculation error occurred, the contractor shall notify DHA and
request appropriate adjustments to incentive payment(s) within 90
calendar days following receipt of the hospital notification and
all substantiating documentation.
7.1.4 Hospital
maternity care incentive payments under this pilot shall be excluded
from National Cost Trend Incentive calculations.
7.1.5 At the Government’s discretion,
hospitals that are active subjects in fraud or abuse investigations, including
civil prosecution and civil litigation, may be deemed ineligible
for P-BMP incentive payments. If the investigations are later resolved,
and it is determined that the hospital did not commit fraud or abuse,
the hospital may be eligible for retroactive P-BMP incentive payments
at the normal rate. Hospitals with confirmed fraudulent or abusive
actions are ineligible for P-BMP incentive payments.
7.2 Incentive Payment Calculations
Beginning in 2019, and on an
annual basis thereafter, the contractor shall issue incentive payments
(from non-underwritten funds) as determined by the Government to
eligible network hospitals, using the Leapfrog rating as of that
date. The Government will calculate incentive payments as a percentage
of total TRICARE allowed charges for TRICARE maternity cases with
admission dates in the applicable incentive cycle (Medicare Severity-Diagnosis Related
Groups (MS-DRGs) 765-768, 774, and 775) as follows:
7.2.1 High Value Tier
(hospital met the target for all four core metrics): Hospital receives
High Value incentive payment (equal to 2% of allowed charges on
all TRICARE deliveries (MS-DRGs 765-768, 774 and 775) that occurred during
the applicable incentive cycle).
7.2.2 Value Tier
(hospital met the target for three core metrics): Hospital receives Value incentive
payment (equal to 1% of allowed charges on all TRICARE deliveries
that occurred during the applicable incentive cycle).
7.2.3 High-Risk Delivery Tier:
High
Value and
Value tier hospitals that also achieved
a
High-Risk Deliveries tier rating will receive an
additional incentive payment (equal to 1% of allowed charges on
High-Risk TRICARE deliveries that occurred during the applicable
incentive cycle). High-risk TRICARE deliveries include all deliveries
with 2018 International Classification of Diseases, 10th Revision,
Clinical Modification (ICD-10-CM) diagnosis code series O09.XX with
admission dates in the applicable incentive cycle and performed
at facilities with the
High-Risk Delivery tier designation.
Note: Hospital claims must include
an ICD-10-CM diagnosis code in the O09.XX series in order to be
included in incentive calculations. The Government will not retroactively
search for high-risk pregnancy diagnoses in outpatient maternity
care claims for incentive calculation purposes. Contractors shall
ensure that hospitals are aware of this process.
7.2.4 Hospitals who met two, one,
or zero core metrics, or who chose not to participate in the Leapfrog Hospital
Survey (or who are rated “not applicable” by Leapfrog), even if
they fully met the Leapfrog standard for High-Risk Deliveries will
not receive incentive payments.
7.2.5 The contractor
shall provide annual feedback reports to participating providers
and hospitals in the purchased care sector regarding their cost
and quality performance and their eligibility for a positive incentive
(as determined by the Government). These feedback reports shall
be provided to participating providers and hospitals no later than
30 calendar days following the Government’s completion of the annual
data analysis and determination of incentive payments.
7.2.6 Contractors shall follow normal
processes and procedures for non-underwritten manual check requests for
P-BMP incentive payments. Contractors shall request funding approval
from the DHA, Contract Resource Management (CRM) Office prior to
issuance of P-BMP incentive checks/Electronic Funds Transfers (EFTs)
to hospitals. P-BMP incentive payments shall not be reported on
the TRICARE Encounter Data (TED).
7.2.7 See
Addendum B for specific data elements for
P-BMP reporting purposes.
7.2.8 See
Addendums C and
D for specific
incentive calculation processes and procedures.