Episode Grouper for Medicare

The goal of this contract is to modify an existing episode grouping software product for use by the Medicare program. The grouping processes and logic shall be readily understandable, transparent, and comprehensible to multiple stakeholders, including physicians, policy makers, and administrators. The logic shall be valid and reliable, and have a reasonable number of homogenous cost groupings (not thousands). Conceptually, episode grouping is comprised of three sub-systems or modules: clinical logic, episode construction logic, and the risk adjustment method. Each of these subsystems can stand on its own, or be integrated with the other components into a software program that groups claims into episodes. The Approach A is organized by these sub-systems. This contract is only for episode grouping software and its components. Elements of a profiling system (attribution rules, benchmarking, standardized costs, etc.) may be considered in the design of data items that will be part of the grouper software's output design. Use of these elements will be determined by the vendor in collaboration with CMS.