Frequently Asked Questions

The UnitedHealthcare Care Bundles Program is an alternative payment model driven by “bundled” episodes of care. The program is a retrospective shared risk model with two offerings housed on one platform:

  1. Retrospective bundles for UnitedHealthcare Medicare Advantage patients
  2. Retrospective bundles for Centers for Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement Advanced (BPCI-A) Medicare Fee for Service (FFS) patients.

For both offerings, a target price is established based on historical claims data for each episode of care, e.g. spine surgery. The historical claims costs are based on all acute and post-acute services associated with the bundle.

You can generate savings by performing below the target price and meeting quality metrics. In doing so, you’ll be eligible for shared savings; however if you perform above the target price, you’ll need to make a repayment. In both scenarios, there’s a stop loss and a gain share limit.

Our UnitedHealthcare Care Bundles Program will support you if you wish to participate in either or both the CMS BPCI-A, or UnitedHealthcare Medicare advantage retrospective bundle offerings. By having both bundle models managed on a common platform, you can drive positive clinical and financial outcomes across UnitedHealthcare and CMS offerings.
Additionally, we offer post-acute care management services, provider/patient facing technology and comprehensive data and analytics that give you end-to-end support.

The offering for CMS FFS patients follows the CMS BPCI-A model in all instances. The offering for UnitedHealthcare Medicare Advantage patients closely follows the CMS BPCI-A model, but there are some differences, which are explained further in this FAQ.

The UnitedHealthcare Care Bundles Program provides scalable, reliable, end-to-end people, process and technology solutions giving you the ability to participate in bundles without additional administrative burden. Our tailored capabilities and services include bundle selection consulting, performance analytics, care management technology and resources, financial risk and payment administration.

CMS Medicare Fee for Service:

IP: Inpatient | OP: Outpatient

Cardiac Bundles

  • IP Acute Myocardial Infarction
  • IP Cardiac Arrhythmia
  • IP/OP Cardiac Defibrillator
  • IP Cardiac Valve
  • IP Congestive Heart Failure
  • IP Coronary Artery Bypass Graft
  • IP Pacemaker
  • IP/OP Percutaneous Coronary Intervention
  • IP Transcatheter Aortic Valve replacement

Spinal Bundles

  • IP/OP Back & Neck (Except Spinal Fusion)
  • IP Cervical Spinal Fusion
  • IP Combined Anterior Posterior Spinal Fusion
  • IP Spinal Fusion (Non-Cervical)

Orthopedic Bundles

  • IP Double Joint Replacement – Lower Extremity
  • IP Fractures of the Femur and Hip or Pelvis
  • IP Hip & Femur Procedures (Except Major Joint)
  • IP Lower Extremity/Humerus Procedure (Except Hip, Foot, Femur)
  • IP/OP Major Joint Replacement – Lower Extremity
  • IP Major Joint Replacement – Upper Extremity

UnitedHealthcare Medicare Advantage:

IP: Inpatient | OP: Outpatient

Cardiac Bundles

  • IP Cardiac Valve
  • IP Coronary Bypass
  • IP/OP Percutaneous Coronary Intervention

Orthopedic Bundles

  • IP Hip (double) Joint Replacement
  • IP Knee (double) Joint Replacement
  • IP/OP Knee (single) Replacement
  • IP Hip (single) Replacement

Spinal Bundles

  • IP Spinal Fusion (non-cervical)

Under CMS BPCI-A, a Medicare beneficiary entitled to benefits under Part A and enrolled under Part B for the entirety of a Clinical Episode on whose behalf an Episode Initiator submits a claim to Medicare FFS for the Anchor Stay or Anchor Procedure associated with the Clinical Episode for which a Participant has committed to be held accountable. For UnitedHealthcare Medicare Advantage, designated Medicare Advantage Individual and Group Retiree Members are included.

Yes, quality measures play a critical role in any value-based program. In the UnitedHealthcare Care Bundles Program, each bundle has a set of quality measures. Depending upon performance, the quality measures could affect your savings or reduce the amount you need to repay.

The duration of the bundle is the same across all bundle types:

  • For an Inpatient Bundle, the duration includes: Trigger period (admit to discharge) + 90 days following discharge
  • For an Outpatient Bundle, the duration includes: Trigger period (admit to discharge) + 90 days following completion of the outpatient procedure

Service Inclusions

Trigger Period: Types of services included in bundle include: Physicians’ services, inpatient or outpatient hospital services during the trigger period.

Post Trigger Period: Other outpatient services, inpatient hospital readmission services, long term care hospital (LTCH) services, inpatient rehabilitation facility (IRF) services, skilled nursing facility (SNF) services, home health agency (HHA) services, clinical laboratory services, durable medical equipment (DME), Part B drugs and hospice services.

Service Exclusions

Blood clotting factors to control bleeding for hemophilia patients, new technology add-on payments and Outpatient Prospective Payment System (OPPS) pass-through devices

Readmission Exclusions

Single list of excluded MS-DRGs will include 122 MS-DRGs: Transplant & Tracheostomy, Trauma, Cancer (when cancer is explicitly indicated by MS-DRG) and Ventricular Shunts.

The UnitedHealthcare Care Bundles Program will begin on January 1, 2020. For CMS BPCI-A members, the program runs through December 31, 2023.

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