Introduction to Radiation Oncology Model
The Radiation Oncology Model aims to improve the quality of care for cancer patients receiving radiotherapy (RT) and move toward a simplified and predictable payment system. The RO Model tests whether prospective, site-neutral, modality agnostic, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for RT episodes of care reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.
Delayed Implementation of Radiation Oncology Model
The alternative payment and care delivery model for cancer care aims to improve the quality of care for patients who receive radiotherapy and establish a predictive, simple payment system for providers who deliver those services. The model would do that through site-neutral bundled payments for a 90-day episode of radiotherapy and related services.
Providers in randomly selected areas would be required to participate, according to program rules. However, cancer care providers have questioned the model’s methodology, particularly its mandatory nature, since it was announced in 2019.
CMS believes that the Radiation Oncology Model would address long-standing concerns related to RT delivery and payment, including the lack of site neutrality for payments, incentives that encourage the volume of services over the value of services, and coding and payment challenges.
However, CMS decided to postpone the launch date given the legislative delays and persistent criticisms from industry stakeholders who have called for change. The agency also announced in the final rule that it would redefine the performance periods.
In Aug 2022, CMS made an announcement that it will propose a new start date for the Radiation Oncology Model via future rulemaking. Moving forward, CMS plans to propose a new start date “no less than 6 months prior to that proposed start date i.e., Jan 2023”.
Things to Know Prior to Implementation of Radiation Oncology Model
Radiation Oncology Model Design
The RO Model is a mandatory model that tests whether changing the way RT services are currently paid, via fee-for-service payments – to prospective, site-neutral, modality-agnostic, episode-based payments incentivizes physicians to deliver higher-value RT care. The design of the RO Model includes several key programmatic elements:
1. Alternative Payment
- Episode Payments: CMS makes prospective, episode-based (i.e., bundled) payments, based on a patient’s cancer diagnosis, that cover RT services furnished in a 90-day episode for the included cancer types meeting the included cancer type criteria described in the final rule;
- Site-neutrality: The Model uses site-neutral payment by establishing a common, adjusted national base payment amount for the episode, regardless of the setting where it is furnished;
- Professional and Technical Payment Components: Episode payments are split into professional and technical components to allow the current claims systems for the Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS) to be used to adjudicate RO Model claims and for consistency with existing business relationships.
Source: freepik.com
2. Linking Payment to Quality
The Model links payment to quality using reporting and performance on quality measures, clinical data reporting, and patient experience as factors when determining payment to RO participants.
The Model meets the requirements to qualify as an Advanced Alternative Payment Model (APM) and a Merit-Based Incentive Payment System (MIPS) APM under QPP starting in performance year (PY) 1.
RO Model Participants
RO Model participants can participate in the Model as Professional, Technical, or Dual participants. Some RO participants, like Physician Group Practices (PGPs), can be both Professional participants and Dual participants depending on the RT services they furnish during the RO episode.
- A Professional participant is a Medicare-enrolled PGP, identified by a single Taxpayer Identification Number (TIN) that furnishes only the Professional Component (PC) of RT services at either a freestanding radiation therapy center or a Hospital Outpatient Department (HOPD).
- A Technical participant is an HOPD or freestanding radiation therapy center, identified by a single CMS Certification Number (CCN) or TIN, which furnishes only the technical component (TC) of RT services during an RO episode.
- A Dual participant furnishes both the PC and TC of an RO episode for RT services through a freestanding radiation therapy center, identified by a single TIN.
RO Model Episode Pricing
RO participant-specific payment amounts are determined based on national base rates, trend factors, and adjustments for each participant’s case mix, historical experience, and geographic location. CMS further adjusts payment amounts by applying a discount factor.
The discount factor, or the set percentage by which CMS reduces an episode payment amount, reserves savings for Medicare and reduces beneficiary cost-sharing. RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY.
RO participants have an opportunity to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and the beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey.
RO Participant Payment
RO episode payments are paid prospectively in the RO Model, meaning that half of the episode payment amount is paid when the RO episode is initiated, and the second half is paid when the RO episode ends.
Episode payments in the RO Model are split into a PC payment; which is meant to represent payment for the included RT services that may only be furnished by a physician; and a TC payment, which is meant to represent payment for the included RT services that are not furnished by a physician, including the provision of equipment, supplies, personnel, and costs related to RT services.
This division reflects the fact that RT professional and technical services are sometimes furnished by separate providers or suppliers.
Quality Measures
The RO Model includes four quality measures. These measures allow the RO Model to apply a pay-for-performance methodology that incorporates performance measurement with a focus on clinical care and beneficiary experience with the aim of capturing a reduction in expenditures and preserving or enhancing the quality of care for beneficiaries.
To do this, the Model withholds 2 percent of the PC, and 1 percent of the TC payments for each episode starting in PY3. RO participants have the ability to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting, and performance, and the beneficiary reported CAHPS® Cancer Care Radiation Therapy Survey.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle management services. Even though Radiation Oncology Model is not implemented yet, it’s always beneficial to know the basics of the RO model so that oncology practices can prepare themselves accordingly.
We referred CMS and other reliable sources to share basic information on Radiation Oncology Model for the purpose of provider education. In case you need assistance in oncology billing, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.
Reference:
Radiation Oncology Model
CMS Delays Radiation Oncology Model With No New Start Date
FAQs
1. Why is medical billing in outpatient cancer care centers so complex?
Medical billing in outpatient cancer care is complex due to the variety of services like chemotherapy, radiation, and lab tests, which can be marked up far beyond Medicare reimbursements.
2. How do billing practices vary across cancer care centers?
Billing practices can vary significantly, with some cancer centers charging up to 4.1 times more than what Medicare reimburses, leading to high financial burdens for patients.
3. What is the issue with price transparency in cancer care billing?
The lack of price transparency in cancer care billing causes unexpected financial challenges for patients, as some centers engage in practices that inflate costs without clear justification.
4. How do medical billing companies help outpatient cancer care centers?
Medical billing companies with expertise in cancer care ensure accurate billing, compliance with regulations, and transparent practices, improving overall revenue cycle management and reducing costs for cancer care centers.
5. What is being done to protect patients from inflated cancer care costs?
To protect patients, some states are introducing laws to prevent unfair billing practices and protect patients from being held responsible for excessive charges that go beyond what the highest payer will reimburse.
