Specialized Financial Risk Protection

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is an iteration on the original voluntary BPCI Model. The Model is focused on supporting healthcare providers who invest in practice innovation and care redesign to better coordinate patient care and reduce expenditures. The Model provides a single retrospective bundled payment based on a 90-day clinical episode of care duration.

In the BPCI Advanced Model, there are eight clinical episode service lines groups, each with payment tied to defined quality measures and target prices. These groups include:
  • Cardiac Care.
  • Cardiac Procedures.
  • Gastrointestinal Care.
  • Gastrointestinal Surgery.
  • Neurological Care.
  • Medical and Critical Care.
  • Orthopedics.
  • Spinal Procedures.

Our Focus on Specialized Risk Protection

Coverys can provide specialized financial risk protection for healthcare providers who plan to participate in value-based programs developed by the Centers for Medicare and Medicaid Services (CMS). These CMS programs have the potential for downside financial risk as well as financial benefits.

Assessing the Options & Alternatives

Participating providers in the BPCI Advanced Model have options and alternatives for handling the potential for downside financial risk. In BPCI Advanced, CMS provides a 20% stop-loss and stop-gain policy that is applied at the Episode Initiator (EI) level. Our coverage, if elected by the participant, can provide stop-loss protection at the aggregate level. Our team will illustrate how these unique and distinct coverage methods work and the manner in which they reduce participants' downside financial exposure and affect their CMS reconciliation and costs of participating in the Model.

Downside Risk Insurance for Provider Financial Protection

For providers who participate in the BPCI Advanced Model, it is important to note that if the provider’s costs exceed the target price, the provider is responsible for paying back losses to CMS. If provider costs stay below the target price, the provider can retain savings based on quality performance.

Key Coverage Highlights:
  • Coverage aligns with CMS program design and rules, and accounts for potential program changes during the performance period (e.g., CMS COVID waivers, program amendments).
  • Premiums developed through experience rating models which account for existing CMS protections.
  • Coverage protects from both technical and programmatic risk.
  • Stop-loss claim payments align with shared losses determination and reconciliation schedule, with claims paid in full at time of reconciliation.
  • Medicare’s reconciliation calculation is validated; contestable errors are identified.
  • Flexible Coinsurance & Deductible options with high, medium, and low deductible options tailored to risk tolerance and experience.
  • Up to 100% coinsurance in excess of aggregate deductible.
  • Flexible payment options—monthly, quarterly, semi-annual, paid in full—all available.
  • Performance reporting.

Why Coverys?

Coverys is a proven leader in providing specialized coverage in the healthcare marketplace for over 45 years. With our Value-Based Care team, Coverys provides downside financial risk protection for healthcare provider participants working in CMS value-based care programs.

This webpage is intended to be informational and is solely for the use of properly licensed insurance professionals. The information contained herein does not constitute an offer to sell any product or service and does not include all policy terms, conditions and exclusions. Please refer to the actual policy for complete details of coverage and exclusions.

Coverage is provided by Coverys Specialty Insurance Company, a New Jersey domestic surplus lines insurer. Coverys Specialty Insurance Company is an excess/surplus lines insurer which is not licensed by or subject to the supervision of the insurance department of your state.

Any inquiries regarding the subject matter set forth herein should be directed through duly licensed surplus lines brokers.