How does the SNF Bill Under CJR (Comprehensive Joint Replacement)?

The important thing to understand about the bundled payment process, whether under the voluntary bundled care initiative or mandatory Comprehensive Joint Replacement program, is that each provider continues to bill Medicare for services provided in the same manner they always have and will be paid by Medicare per RUGs, just like non-CJR patients

This means the SNF will continue to complete Medicare required assessments for payment and submit a claim to Medicare for reimbursement. In order for a SNF Medicare Part A claim to process, there must be a 3 day qualifying stay reported on the claim by appending the appropriate code FL claims without a 3 day with bypass the 3 day hospital stay edit and process for payment. It is important to remember specific criteria must be met in order to use this code:

  • 3 out 5 star rating for 7 out of 12 months for bundled payments 
  • CMS posts a complete list of participants that meet the criteria

The difference comes with the retrospective reconciliation between CMS and the hospital comparing actual episode costs to target costs per DRGThe hospital does not pay the SNF for care. The only time there would be payment from the hospital is if the SNF and hospital entered into a risk-sharing agreement for the SNF to share some of the risk and potentially some of the gain.

This may result in either a bonus payment or repayment amount being awarded to the episode conveyor or the hospital. SNFs may set up agreements with hospitals to gain/risk share which could result in a payment or bill from the hospital, but this occurs outside of their payment from Medicare.