Medicare’s Comprehensive Care for Joint Replacement Model

Medicare’s Comprehensive Care for Joint Replacement Model

Saint Michael's Medical Center is participating in a Medicare initiative called the Comprehensive Care for Joint Replacement (CJR) model. The CJR model aims to promote quality and financial accountability for care surrounding lower-extremity joint replacement (LEJR) procedures, commonly referred to as hip and knee replacements and/or other major leg procedures. Saint Michael's Medical Center participation in the CJR model should not restrict your access to care for your medical condition or your freedom to choose your health care providers and services. All existing Medicare beneficiary protections continue to be available to you. These include the ability to report concerns of substandard care to Quality Improvement Organizations and 1-800-MEDICARE.

The CJR model aims to help give you better care.

Saint Michael's Medical Center has entered into financial arrangements with collaborating health care providers who are engaged in care redesign with the hospital and who may furnish health care services to Medicare beneficiaries during an episode of care. Under these agreements, Saint Michael's Medical Center may share payments received from Medicare as a result of reduced episode spending and hospital internal cost savings with collaborating providers and suppliers. Saint Michael's Medical Center may also share financial accountability for increased episode spending with collaborating providers and suppliers. The following list includes health care providers and suppliers that have established a collaborator agreement with Saint Michael's in order to share in financial rewards and/or losses in the CJR model.

Ronald E. Gennace, MD
312 Belleville Turnpike, North Arlington, NJ 07031

Richard A. Boiardo, MD
769 Northfield Ave, West Orange, NJ 07052

CJR Selection Criteria Policy

PURPOSE:

  1. Saint Michael's Medical Center (hereinafter "SMMC") is a participant in the Comprehensive Care for Joint Replacement (hereinafter "CJR") Model as outlined in the Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services Final Rule Issued by CMS on November 24, 2015, as further amended December 1, 2017 ("CJR Final Rule") for the remainder of the term.
  2. Participation in the CJR Model allows SMMC to collaborate with physicians, and other providers, in the coordination of care to patients receiving services that are a) related to lower extremity joint replacement, and b) covered under the CJR Model.
  3. SMMC wishes to clarify the requirements physicians, and other providers, must meet in order to participate with SMMC in the CJR Model.

POLICY STATEMENTS:

It is the policy of SMMC to require all physicians, and other providers, who collaborate with SMMC to provide patient care under the CJR Model to provide care with the highest level of professional competence and make patient care decisions on the basis of medical necessity and with the best interests of the patient in mind.

This Policy applies to any physician, or provider, wishing to participate with SMMC in the CJR Model.

I. CJR PHYSICIAN PARTICIPATION REQUIREMENTS

In order for a physician or provider to participate in the CJR Model with SMMC, through his or her respective group practice, the physician or provider must meet each of the following requirements:

  1. Meet and continue to meet the criteria for Hospital's Medical Staff membership set forth in its Medical Staff Bylaws;
  2. Maintain at all times clinical privileges to practice commensurate with the Covered Services to be performed under Sharing Agreement at Hospital;
  3. Be a participating provide in the Medicare Fee for Services Program;
  4. Be duly licensed in good standing by the New Jersey State Board of Medical Examiners;
  5. Hold a current narcotics number issued by the appropriate governmental agency;
  6. Comply with applicable requirement of the accreditation agency of the Hospital, the Code of Ethics of the AMA, and the bylaws, rules, and regulations, policies and procedures of Hospital and its Medical Staff.
  7. Comply with the applicable terms and conditions of CJR Final Rule and shall be subject to all submissions to CMS required under the CJR rule;
  8. Provide Hospital and CMS access to the records, information and data of Physician for purposes of monitoring and reporting as may be required under the CJR or the CJR Final Rule, and provide CMS access as may be required by applicable law for any other lawful purpose;
  9. Comply with any corrective action plan instituted pursuant to the CJR Final Rule;
  10. Comply with all applicable laws, rules and regulations of the United States, the State of New Jersey, and any other applicable governmental agency in performance of and the billing for Covered Services;
  11. Must not engage in any wrongful personal or professional conduct which, in the reasonable determination of Hospital, does or may adversely affect Hospital's performance and obligations under the CJR Final Rule;
  12. Must not engage in any activity that, in the sole and reasonable determination of Hospital, jeopardizes or may jeopardize Hospital's status as a tax-exempt organization under Internal Revenue Code ("Code") 50l(c)(3);
  13. License to practice medicine may not be revoked, restricted, suspended or terminated, or have any formal disciplinary action or censure of the Physician as a final act of any State medical licensing authority, which would impede Physician's ability to provide Covered Services pursuant to Sharing Agreement;
  14. Must not engage in any fraudulent practice of willful misconduct.

II. SMMC PARTNERSHIP WITH PHYSICIAN PRACTICE GROUP IN CJR MODEL

SMMC will collaborate with physicians in the CJR Model by entering into a sharing arrangement with each participating physicians' respective practice group ("Sharing Arrangement"). Each physician participating in the CJR Model shall be bound by the obligations of the Sharing Arrangement between SMMC and their respective practice group by signing a joinder to their group practice's Sharing Arrangement with SMMC ("Physician Joinder Agreement"). Before SMMC enters into a Sharing Arrangement with a group practice, SMMC shall confirm all physicians who will participate in the CJR Model through the Sharing Arrangement have met the requirements outlined in Section I of this Policy, which shall include verifying each physician's privileges at SMMC. SMMC will require all physicians who participate in the CJR Model with their group practice to sign the Physician Joinder Agreement contemporaneously with their group practice signing the Sharing Arrangement. ·

It is the intent of SMMC and the physician groups to improve the quality and efficiency of services provided in connection with the CJR Final Rule and not to limit or reduce items or services to patients of SMMC. In furtherance of the foregoing, physicians group and each provider shall fully cooperate with any and all quality assurance measures established by SMMC to ensure that the performance improvement initiatives integral to the Sharing Arrangement do not have the unintentional consequences of limiting or reducing items or services to patients or adversely affecting quality care.

Under no circumstances will the selection criteria be based directly or indirectly on the volume or value of past or anticipated referrals or business otherwise generated by, between or among SMMC, any CJR collaborator, any collaboration agent, any downstream collaboration agent, or any individual or entity affiliated with SMMC, CJR collaborator, collaboration agent, or downstream collaboration agent.

III. NOTICE OF FAILURE TO MEET THE CJR SELECTION CRITERIA REQUIREMENTS

SMMC shall require, pursuant to Section 4 of the Sharing Arrangement, physician's respective group practice to immediately notify SMMC of an event, occurrence, or change in status that results in a group practice physician or provider no longer meeting one, or more, of the requirements contained in Section I of this Policy. SMMC shall require, pursuant to Section 4 of the Sharing Arrangement, physician's respective group practice to immediately notify SMMC of any threat by a governmental authority having jurisdiction over physician or provider to impose any sanctions referenced in Section I of this Policy.

IV. EFFECT OF FAILURE TO MEET THE CJR SELECTION CRITERIA REQUIREMENTS

SMMC shall immediately remove from the CJR Model a physician or provider who fails to meet the requirements contained in Section I of this Policy by removing that physician from the List of Group Physicians in Exhibit A to the Sharing Arrangement.

Download the CJR Selection Criteria Policy