Prepare for TEAM, Coming January 1
Hundreds of facilities are impacted nationwide. Are you part of this new mandatory model? Per the Centers for Medicare & Medicaid Services (CMS), the Transforming Episode Accountability Model (TEAM) is a mandatory, episode-based payment model. It is designed to help improve the patient experience from surgery through recovery by supporting the coordination and transition of care between providers. However, CMS explains that under the existing fee-for-service (FFS) payment system, providers and suppliers are paid separately for each service and procedure. They acknowledge that this system allows for the possibility of fragmented care, duplicate use of resources, and avoidable utilization. And they concede this can lead to complications in recovery, avoidable hospitalizations, and other high costs. TEAM will test this new payment approach using select acute care facilities. Read on to find out what you need to know about TEAM. Get In the Game by Understanding TEAM Basics TEAM begins January 1, 2026, and continues until December 31, 2030. CMS has defined timelines for each of the model’s performance years (PYs) as: Participation: CMS chose participants from facilities across the United States that are paid under the Inpatient or Outpatient Prospective Payment System (IPPS or OPPS) and fall within defined geographic regions. The selected hospitals will receive a target price to cover all costs associated with an episode of care, including all the costs related to the hospital inpatient stay or outpatient procedure, and all items and services following discharge, including skilled nursing facility (SNF) stays and provider follow-up visits. TEAM also offered a one-time voluntary opt-in opportunity. Several facilities decided to join the model. All participants, regardless of how they became involved, will be required to coordinate care from the point of surgery through 30 days post-procedure or hospital departure. This new approach is initially limited in scale. PY1 is confined to original Medicare patients that undergo one of the following surgical procedures: lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass grafts, or a major bowel procedure. An episode of care starts with either a hospital inpatient stay, called an anchor hospitalization, or a hospital outpatient procedure, referred to as an anchor procedure. Important: The hospital’s accountability for an episode of care includes both facility and professional services. Find Out the Compensation Rules TEAM participants will continue to bill Medicare FFS but will receive their facility’s calculated target price. Participants’ performance will be evaluated by comparing actual Medicare FFS spending for the episode to their target prices, as well as assessing their performance on specific quality measures. TEAM participants can earn a payment from CMS if the total Medicare costs for the episode are below the target price, or they may owe a repayment if total costs are above the target price. Both are subject to any quality performance adjustment. TEAM also allows different levels of risk/reward through a one-year initial glide path, in which participants choose a participation track allowing them to ease into full-risk involvement. Track 1 has no downside risk and is available to all TEAM participants in PY1. Note that some hospitals are eligible to remain in Track 1 for the first three PYs. Tracks 2 and 3 have a two-sided risk. Track 2 has lower levels of financial risk and reward. It is available to certain hospitals, such as rural hospitals, starting in PY2-PY5. Track 3, on the other hand, has higher levels of financial risk and reward. It is available to all TEAM participants from PY1-PY5. Helpful: Each track has stop-gain and stop-loss limits that cap the total amount that can be received or owed. For an illustrative risk chart, see page 12 of CMS’ TEAM webinar. Take Note of Medicare Rule Waivers To support the management of patient care by participating hospitals and to allow for enhancement of care coordination across the post-acute spectrum, CMS has decided to conditionally waive certain Medicare payment requirements. Example: One waived requirement permits TEAM-participating hospitals to discharge patients to qualified SNFs and swing bed providers, including critical access hospitals (CAHs), without a qualifying three-day hospital stay. There are however other requirements that will apply, including but not limited to the patient meeting TEAM eligibility criteria; for example, the patient must have Medicare Part A and B, not be part of a managed care plan, not have end-state renal disease (ESRD) as a basis for eligibility, nor be covered under a United Mine Workers of America health plan. Medicare must be the primary payer to meet TEAM eligibility. Warning: The SNF also must be qualified to admit patients under TEAM. The admission date must happen no later than 30 days after discharge/outpatient procedure. The SNF claim must also meet certain payment criteria, including submitting the claim with the required A9 (TEAM demonstration) code. There are resources available to stay up to date with TEAM specifics. To discover more, start with the fact sheet, which outlines TEAM requirements in more depth. Next visit the TEAM website. Discover the participant list (updated quarterly), learn more about the risks/rewards of each participation track, read FAQs, and uncover billing procedures and waived Medicare requirements. Finally, subscribe to the listserv for updates, including any future model modifications. Patricia Zubritzky, BS, CRCE-I, Contributing Writer, Pittsburgh
