Understanding the CMS Team Model

With the launch of the CMS TEAM Model, nearly 1,000 hospitals across the U.S. are entering a new era of accountability, care coordination, and financial risk. For the first time in recent history, CMS is mandating that selected hospitals take full responsibility for the cost, quality, and outcomes of care delivered across post-acute networks for five major procedures. 

On this week’s Compliance Conversations podcast, CJ Wolf sits down with Eddie Qureshi, CEO of Rainfall Health, to unpack what hospitals need to know. From compliance readiness assessments to AI-powered documentation and reporting tools, Eddie explains how hospitals can prepare to succeed under the TEAM Model—and avoid costly penalties. 

This is a must-listen episode for compliance, quality, and finance leaders navigating the future of Medicare reimbursement. 

Episode Transcript

Welcome, everybody, to another episode of Compliance Conversations. My name is CJ Wolf with Healthicity, and today's guest is Eddie Qureshi. Eddie, welcome to the show. Thanks for having me, CJ. Great to be here. Yeah, and I am so excited that we have you today. And this topic that we're going to talk about, we'll introduce the topic in a moment. I didn't know a lot about it, and it's going to have some impact. So compliance officers, listen to Eddie and what he has to share. But before we do that, Eddie, we'd love to just hear a little bit about yourself and feel free to introduce yourself and share what you're doing. 

Absolutely. My name is Eddie Qureshi. I'm the founder and CEO of Rainfall Health. I'm a trained scientist by background, and I've been in healthcare my entire career. With Rainfall Health over the last five years, it's been really exciting to build an AI-enabled tool to help executives around maximizing their reimbursement and providing accountability and accessibility software to make so much impact. And with these new mandated models, we're really excited to help probably your listeners go from stressed to successful. 

Yeah, absolutely. Well, you know, I didn't know a lot about this topic, but in preparation, I was reading a little bit more about it and I was shocked that I didn't know about it. And we were talking about this before we started the show, that that's something that you run into a lot of. And so we're going to be talking today about the CMS team model. And so maybe you can just, since I didn't know a lot about it, maybe you can just give us a brief explanation of what it is and why it's going to be such a significant shift in Medicare reimbursement over the next decade. 

Absolutely. So Centers for Medicare and Medicaid Services came out with a new innovation model called TEAM, and it stands for Transforming Episode Accountability Model. It's a mouthful, but really the premise of it is very simple. It makes it the sole responsibility of the hospital, and they listed out the mandated facilities. There's about 745 of them overall, about 1,000 hospitals around the country in about 47 states. are impacted and listed by name. If you're unsure, just go to medicare.gov and you can find that entire Excel sheet and look up your hospital. But these hospitals now are responsible for all of the post-acute and procedural care for five procedures to start. It's lower extremity joint replacement, spinal fusion, surgical hip and femur fracture treatment, major bowel procedure, and cabbage coronary artery bypass graft. Now, These five procedures, why this model is a big deal, is they make up roughly about 20% of the annual Medicare reimbursement for these facilities. If I were to come to you and say, I can give you an impact on that 20% of annual Medicare reimbursement, I think a lot of executives would listen. So that's why, just from a financial standpoint, why it's such a big deal. Secondly, why it's so impactful is Over the last really 17 years, since the last infrastructure mandate of this size came out, which was the EHR mandate back in 2008, We actually built the US healthcare system so that it was very facility focused, right? Everyone has their own EHRs and you get to document things and you get to share things. And there's some ability for the EHRs to go in and out of the hospital, but really it was very internally focused. And you go from one EHR to another EHR somewhere else. This model actually breaks that down entirely. It says, like the acronym implies, it's a team-based model. It actually forces you to have all of the post-acute network your responsibility as a hospital. That means, imagine skilled nursing facilities, home health, outpatient services, even hospice are your responsibility from an outcome perspective, as well as care coordination. But getting patients from your facility for a procedure to the post-acute care is now a really big deal. And anybody who's done it knows there's infrastructure involved. The second piece of it is not only do you have to get patients there, not only do you have to answer for somebody else's outcomes, you as a hospital have to pay for it. Now, let me let that sink in for a second. you have to pay for it. That means you're negotiating those rates. You are actually paying them out and you're capitated. So that means that if you go over costs, not only do you take that burden on yourself as a facility where in the current, when we're recording this podcast in July of 2025, hospitals are already on razor thin margins with sometimes having 15, 25 days of runway in the bank. Right. But this model actually says that, If you don't keep costs and quality where you're expected to and report it out as well, you not only might have gone over costs and have to take that burden on yourself, you're actually going to be penalized up to 20% of your reimbursement for that as well. Now, it's not all bad news, right? We're talking about liability. This is also an opportunity. Because we've also seen these models come together, push us forward in the direction that people want, especially your audience, the compliance and quality and leadership and strategic initiatives that it takes to start being that standout. And you get rewarded as well. So we talked about the 20% penalty payments. There's also a 20% incentive for people who do everything correctly. So that's the model in a nutshell. And from a patient and just an An American constituent, you should be incredibly excited that we're finally starting to see some movement towards a more holistic and integrated approach to healthcare. 

Yeah, that's a great kind of background. And what shocked me as I was learning about it is, I've been in healthcare for 25 years and CMS comes out with models, but they're usually like you opt in. This one, they said, we're requiring it. of these hospitals. And so I don't know if I've ever seen that before, where CMS said, we are going to require it. And to your earlier point, there's a list. So my first question to our listeners is, do you even know if you're on that list? So go check it. Like Eddie said, you can just Google CMS team model, and you'll find a lot of information about it. And Eddie, a lot of our listeners, our compliance folks, we know that whenever money's involved, you have to make sure you're following the rules because there's always audits and those sorts of things. Like you said, there's incentives. And whenever there's incentives, people might want to cut corners to meet those financial incentives. There may be penalties. And so people sometimes rationalize and justify decisions because they know they're going to get hit hard financially. And so I'm kind of curious just... What are some of the biggest gaps that you are seeing in readiness, you know, for around the care coordination and documentation that go along with this model? 

Absolutely. And it's so interesting that you brought that up because we actually that's the very first step. The first time one of our partners reaches out, we say, let's do a readiness assessment. And that's where our first exposure to our AI and our dashboard comes in at that point. We actually pull in relevant look-back periods, which is pretty common for CMS to say, we're going to look back at a certain period of performance to gauge how you should be judged for the next few years. So this model is five years long. So looking back three years and then kind of setting up your sort of bar for the next five. the readiness assessment so far, not just by us, but actually by Medicare is not yielding optimistic results. And the reason is Medicare actually expects over half and as much as three fourths of hospitals to lose money on this model. And that's not because it's, they haven't been doing a good job. It's because they've never had to take on this sort of burden of dealing with their own reporting, their own compliance and data management, but also doing it for an entire network. So it's really the infrastructure problem and that's where we come in, right? So there's a readiness assessment and the main areas of gap analysis, as it sounds, we actually look at the workflow management, the care coordination flow, as well as the integrations and reporting. And our AI actually builds out workflows and says, you're actually missing entire components of care that are your responsibility, right? So those will become cost drivers if you don't keep an eye on them. And then it goes into how do you compliantly, you hit the nail on the head, you have to compliantly fill those gaps. Because one of the things that we have learned from previous models that have come up, like BPCI, CJR, your audience will know about these, it has been where If you incentivize, for example, some of your physician groups, your outcomes actually improve. Your costs actually improve. But now this model actually has multiple structures of gain share built into it. So how do you not only take the learnings from the past, but now apply them in a sustainable and compliant way to get prepared for the future? And that's really our job. And we kind of are that co-pilot. But those are the main areas from care coordination to compliant gap analysis. That's inherently the first step. 

Well, let me ask you, as you're working with clients, hospital clients, who typically are the people? Are these CFOs? Are these quality officers? Are these medical directors? Like who's usually at the table when you go in and try to help a hospital? 

Absolutely. So, you know, I'm just going to plug in my podcast here for a second and talk about I just had the chief legal officer of Bassett Health, Paul Urich, on our podcast. And he actually said it best. He said this is not a single department or single executive problem. And, you know, CMS did a really smart job actually of building this for sustainability. It's a very financially focused model. So your CFOs have to get involved because those are big dollars and cents, right? On average, we're seeing impacts of upwards of three and upward and up to $12 million a year on this model for a hospital. Those are big numbers. So your CFO definitely wants to get involved. The COO, the operating officers, it matters because those workflows, those integrations, as well as the beating that integrated network is partially their responsibility as well. And then you as the compliance and quality officers, it's on your report card. You're responsible for making sure these outcomes, reportings are done in the manner that makes sense. And these models are already set to evolve every six months for the next five years. So just as soon as you feel like you have your mind wrapped around it, it could adjust. And that's where a product-based approach that we've really built shows how you can stay ahead of it rather than always be on your back foot responding to these models. But it really does span the entire executive and leadership team 

Yeah, I would think so, right? The team model is going to take a team at your hospital to be successful. And tell us a little bit about kind of documentation and why that's so critical. And I think you guys have a tool that kind of helps handle that complexity. 

Absolutely, absolutely. So it's around three main points, which is how do you have shared accountability? How do you have timely communication and coordination? And then how do you create quality care transitions? And all of this needs to be documented along the way. So the first place to start is to see where are your networks and where are you currently well-prepared? So there are some transitions. If you have a skilled nursing facility affiliated with your system or your hospital, fantastic. so many components of care that now you're fully responsible for that getting that your mind wrapped around it is really important and using it from a data-first lens. So that's where the reporting first starts, is actually getting the lay of the land, seeing the dollars and cents, seeing the outcomes management, and seeing what the reporting is gonna look like. The second one is there's a way to look back right now. In 2025, before the model goes live, the first deadlines actually happen in November, the model goes live January 1st. So this is the year really to get prepared for the next five. Then there's once the sun rises on January 1st, 2026, the model is live and your reporting timeline starts. So that means you need continuous monitoring and you need to be able to report it from across your network. And those quality care transitions are also a big deal because you need to make sure that patients know where they're supposed to go, how they're supposed to get there, be able to get them to those areas and then get the information back in a timely fashion. Now, you know, over here, I want to go broader than just your question and say, there's a statistic I heard from a CIO for leading health system recently that said between 1950 and 2000 healthcare data doubled, right? So it took 50 years to double all the data that we've created. And now, it's doubling every 70 days. Wow. So basically every two and a half months, the data is doubled in the world. So being able to even consolidate it requires modern tools. And that's where AI workflow automation and secure integration to existing infrastructure is going to matter. Just because AI You as an audience of this podcast, we're listening to it and you're feeling your own blood pressure rise. It's not really your fault. It's infrastructure needs to catch up with the demands. But once we do it, it is going to be a more robust and a more impactful system because that's really ultimately, that's why you get into healthcare. That's why you become an executive to make an impact in the lives of patients and in the general healthcare landscape, right? So this is both an opportunity and if not handled well, a 

potential liability. Yeah, absolutely. This is such a great conversation. We're going to take a quick break and then we're going to continue with some more questions for Eddie. Welcome back everyone from the break. Eddie, I want to keep kind of going on where we were discussing right before the break. Tell us some of the core components of this framework. How do they work together to help hospitals kind of meet all of these requirements without having this like administrative overload? Like I can just envision that this is like feeling like an administrative burden. 

Absolutely. So if you were to take this on manually, it absolutely would be a huge burden because consolidating that information. So we do a 30 day engagement and get everybody prepared and understanding what that needs to happen for the next five years. And we do it automatically. We built an infrastructure so that we could pull in the relevant information, visualize it, and then use smart modeling and data science techniques to let people know exactly what they should be choosing. We actually call our framework the rain compliant framework. Now RAINN is actually an acronym as well, and it stands for Referral Accountability for Integrated Networks. So let me break that down for you as part of our framework. So referral is building an intelligent referral framework around getting folks all across the workflow, the entire post-acute, episode and bring that information back. And that's the accountability aspect of it. How do you automate accountability when you're responsible, not just for your facility, which already is kind of a misnomer because you might have physician groups coming in and doing the surgery itself. You know, it's so complex right off the bat that everybody Having that accountability across your procedure, the post-acute network for the same patient who needs to go through several rounds of physical therapy, need a home health agency, have skilled nursing facilities, have those components for medical adherence all in one spot, and then report it out. So starting to act now as an interoperable and integrated network. That's where the I in the ring comes from. And the last one is network optimization. So we not only provide that information analysis in the beginning. Our first engagement is always 30 days to just let people know, hey, is this a fit? Is this where we want to go together? The next part is we actually build out your workflows, see those gaps, and now help fill them. So if there are components of care that your hospital, your facility is missing, we actually bring those to the table, help negotiate in a compliant manner, the agreements and the build that robust workflow so it's optimal for your facility and your patients. So back to your question of how do you not essentially drown in all this administrative burden, it is by saying, how do we leverage the tools at our disposal to create a scalable approach to this model and then be able to respond to it in a compliant fashion pull in the relevant information where we need, and then also be able to see where we are. Are we on track? That's the continuous monitoring aspect of what we've built. And that allows you to pull it all together. And this framework that we built was specifically because we didn't want to see the scars of the past. So those models I mentioned earlier, BPCI, CJR, all your audience members who have experience with them will remember them and not always fondly. And it's because CMMI, you know, the innovation arm, comes out with goals, essentially. And responding, if you ask 745 facilities to respond to a goal, they respond to it in 745 different ways. Right. And ultimately, you know, Medicare gets the final say. And that reconciliation, that's where kind of the fear is. And some people, by the end of some of these models, just started saying, stashing away cap money on the side, assuming that they were going to fail and they would have to pay penalties. Now that strategy doesn't work out for two reasons. One is it's incredibly expensive and not a good use of strategic capital. And also that's too much capital now under this model that is at stake. So stashing that aside is not even going to be a possibility. So, For us, we actually brought together eight different executives from renowned health systems, including Kaiser, including Sanford, UC Health Systems, and Mayo, and we brought them together to say, let's start building a framework that can scale across all systems, regardless of where you are geographically, whether you're Sanford in 24 states, you're Kaiser in over 10 states, and really build a framework that will Scale and work for everybody. And it actually benefits all of us, whether you're a patient or even Medicare, because now you're not needing to deal with all these different, essentially creative ways to respond to the model, but really get to the heart of it and respond to it in a scalable way as it evolves to its final stage. in 2030. What the world's gonna look like, what the structure of healthcare is gonna look like in 2030, I think is open, but we could make this be the blueprint on which healthcare is delivered from here on out. 

Yeah, it's amazing. Let me ask kind of an operational question. I'm assuming Medicare, with all the reporting that has to be done, they have some sort of portal or standardized files or forms that are going to be submitted. Is that assumption correct? 

Yeah, there is a portal. There is responses. For example, even signing up, there's three tracks on the model. The track selection happens in November. But again, getting those things ready, getting them in the standardized format that will ultimately be reconciled in the way that you expect, that's a whole other thing. process that is still the responsibility of the facility as it stands. 

Yeah, we're a cloud-based platform. So we are standalone, but we integrate into your existing infrastructure. And we're able to pull the relevant information and keep track of the relevant data as well. And we do the same thing with our referral partners that we bring to the table that you might already have as partnerships with and have them also respond to the same framework. Think of it kind of like an electronic checklist that we consistently make sure is getting checked. And we use it then to create these reports consistently so that you can make strategic moves based on those requirements. So where you know your quality is high and you're a high performing health system, you want to pick the high risk, high reward track. Otherwise you're losing money on the table, right? And this is millions of dollars. Like, why would you do that? Especially in a time where people are looking for new sources of capital and new sources of revenue. And so that's a big deal. Same thing from a quality lens where you as the, Chief Quality Officer or Chief Compliance Officer have some say in your actual organization, but how are you supposed to mandate training, mandate a certain level of compliance and a high level of outcome management to just your partners? They're also motivated, but how do you create that sort of standardization across the entire episode period? That's, again, our framework is designed with the hospital as the center, But keeping in mind, this actually affects a whole host of other folks in the network as well. So we can span that entire landscape and that entire workflow for the entire episode period. Then we actually enable our AI to make sure that we're capturing those workflows and visualizing them. And the last component, this is where we're really proud of what we've been building for the last several years, even before team was ever announced. was really to create a more consolidated network, essentially creating an ecosystem for healthcare delivery. And now we're applying it. And really what CMS has already said, this is a test for how to do it for essentially all procedures. So if hospitals kind of don't set scalable infrastructure in place for this one, it's not getting easier as more procedures come online. 

That's right. That's so true. And we've seen that. We've seen that in other, you know, kind of transitions, you know, throughout the decades in health care that you can't just close your eyes and hope that it goes away. It's coming. You mentioned AI. So I'm curious about how you guys use kind of this AI driven approach to help hospitals, you know, even capture the missed revenue opportunities, you know, and how do you do that real time kind of risk detection that you are talking about? 

Absolutely. So one of the most important things for us is we are going all in on our technology. And what I mean by that is we're actually willing to go at risk with the facilities that are on this model. Our partnerships are actually built partially at risk. That means that if you are not doing well, we're not doing well. So really, we're aligned. What we're really excited about this entire model is how it aligns incentives. And it would be unfair for us to put ourselves outside of that incentive structures. We're actually part of this crew partners for the entire process. So that's one thing that I want to like talk about, which is a unique approach for just us. There's no one else in the entire market that has a product-based approach going at risk like we are for this model. Like, and that's how confident we are in the framework that we built and the technology that we have. So now our AI here is starting off with pulling in all this information over many, many years across your network, across your core business service area. And this is my first time introducing that here, because even if you're a mandated facility, you're actually being compared against the quality and cost of everybody in your service area, whether they're a mandated facility or not. Now this should be a big deal because now you're starting to understand that it's less of you in a vacuum, which has been the case in previous models where you're essentially, you know, there's a diminishing returns because you're competing essentially against yourself. But this one, you're actually being compared consistently with other folks in your area. And now that's being expanded to not just your, the other hospitals and other, you know, ASCs, you're actually also being compared now to the outcomes of your delivery network. So you want to have a robust network. And our AI here is pretty complex. Those framework questions and the framework data that we're pulling from all these different areas, going from operations, going from compliance, going from clinical, as well as financial, it's actually pretty– it goes very deep and specifically for your– patient population and provides those insights for preparedness and does it both in a forward-looking manner so you can get prepared actually for the next year. There's an entire score. It's a completely novel score. So if nobody's heard about it, they shouldn't be worried. They've never needed to. It's called a composite quality score. And it's going across a whole bunch of different requirements and outcomes management to give each facility a score. And that score will either enhance your incentive payments and buffer your penalty payments if it's a high score, or if it's a low score, it'll exacerbate your penalty payments and buffer your incentive payments. So really, again, quality, compliance are back at the center of this model. And we make sure that people are staying compliant, looking ahead, as well as continuously figuring out, hey, where is my Medicare reimbursement landing so that I'm not surprised when there's a look back period and suddenly Medicare comes knocking, asking for money potentially or hopefully, and this is our goal, is to get you where they're coming with a nice big check for all the hard work that you put in early on. 

Yeah, so fascinating. This is such an important topic. Eddie, we're kind of getting towards the end of our time, but I'd love to have you, if there's any last minute thoughts or maybe a question I didn't ask, anything that you think is important on this topic that our listeners need to hear before we close. Absolutely. I 

think the biggest thing is we, again, since the last big shift here was back in when EHRs were mandated, there's a couple of things that we did as healthcare to respond to it. One was we tried to build actually several different manners to respond. Entire hospitals and health systems took on the challenge and decided to build some themselves. That's right. This sounds good at face value, but the reality is healthcare is complex enough as it is, building an entire, also becoming a software company on top of that is tough. So that's one thing that I like to remind people that we did spend a lot of effort and time creating infrastructure that we had to then decommission to come towards a more standardized approach. So that's number one. So healthcare is better without silos. Number two is we actually, in that period, learned that healthcare can move very quickly in a short period of time when there are these massive shifts in legislation and regulatory landscape. So this, we should take it at that face value again and say, if it sounds scary, it's because we are looking at sort of an unknown, but we can build for it. We actually have infrastructure and modern technology that can outpace some of the infrastructure that we built back in 2000 in the 2000s. Even though iPhone was such an amazing innovation, if I give you an iPhone 1 right now, CJ, I don't know if you'd want to be using it, right? It's because we have evolved technology enough that some of the modern tools are needed to respond to it. And lastly, if your listeners want, we're here to help and we're here to be a resource and really go at risk with the facilities and build something amazing that really impacts healthcare for the long haul. 

Yeah. Oh, great. Thank you so much. And we'll include some links and contact information for Eddie and his team for those of you that would like to reach out to them. Thank you again so much for taking some time to share your insights on this topic. Great to be here. And thank you to all our listeners for listening to another episode. As always, if you know of a guest that you would love to have on the show, please send their name and recommendation. And if you have a topic that you'd like us to cover, please share with us so that we can be sharing with you what you want to hear. So thanks again, everybody. Until next time, take care.