Guides

Enable CMS TEAM Success with ReferWell

From TEAM Compliance to TEAM Excellence ReferWell ensures your surgical episodes succeed by combining intelligent routing technology with hands-on care navigation to convert referrals and prevent readmissions.

The TEAM Reality

30 Days to Make or Break Medicare Patient Post-Op Recovery

The policy requires selected acute care hospitals to coordinate care from surgery through 30 days post-hospitalization for people with, as CMS designates, Original Medicare. Hospitals paid under the Inpatient Prospective Payment System (IPPS) and located in the selected Core-Based Statistical Areas (CBSAs) are required to participate in TEAM to support the value-based care performance model.

Financial Stakes

Up to two-thirds of participating hospitals will lose revenue under TEAM according to Brandeis University analysis.

  • 714 hospitals are mandated to participate
  • 2% discount factor built into target prices
  • One readmission can push an episode over target

30-Day Accountability

All costs for 30 days post-discharge are included in episode pricing, including readmissions.

  • Average readmission cost: $15,200
  • Readmission rates: 10-20% for surgical conditions
  • Quality scores affect reconciliation

5 Surgical Episodes

TEAM covers five high-volume surgical procedures requiring coordination.

  • Lower extremity joint replacement
  • Surgical hip/femur fracture treatment
  • Spinal fusion
  • Coronary artery bypass graft
  • Major bowel procedures

The Challenge

Hospitals need patients to:

(1) Convert referrals → see high-quality, in-network specialists for post-surgical care, and

(2) Not get readmitted → remain healthy and complete their recovery journey without complications.

Financial Stakes

Up to two-thirds of participating hospitals will lose revenue under TEAM according to Brandeis University analysis.

  • 714 hospitals are mandated to participate
  • 2% discount factor built into target prices
  • One readmission can push an episode over target

30-Day Accountability

All costs for 30 days post-discharge are included in episode pricing, including readmissions.

  • Average readmission cost: $15,200
  • Readmission rates: 10-20% for surgical conditions
  • Quality scores affect reconciliation

5 Surgical Episodes

TEAM covers five high-volume surgical procedures requiring coordination.

  • Lower extremity joint replacement
  • Surgical hip/femur fracture treatment
  • Spinal fusion
  • Coronary artery bypass graft
  • Major bowel procedures

Key points

Why Analytics Alone Fall Short

Why analytics alone fall short and how to connect insights to real outreach

Prioritize and Personalize

How to prioritize and personalize engagement with precision

Applying the Framework

A framework for closing care gaps and improving outcomes at scale

Download the case study!

Above guide will show you how to bridge the gap between insights and action, so every interaction is timely, relevant, and impactful.

Want more?

Check out our recent articles, insights, and case studies and see how we dive into helping organizations transform access to care and the outcomes we deliver.

Guides

Turn Analytics into Action: A Strategic Guide to Effective Member Outreach

Guides

Your Strategic Guide to Member Outreach: Build vs. Outsource

Guides

Build or Buy? Choosing the Right Path for Effective Member Outreach

Guides

Streamlining Referral Management: How Real-Time Booking Transforms Provider Operations