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Too Much, Too Fast: Providers Need More Time to Operationalize Medicare's New Radiation Oncology Model

Jessica Walradt manages Northwestern Medicine’s government value-based care portfolio, which includes BPCI Advanced, the Medicare Shared Savings Program, the Oncology Care Model, and components of the Quality Payment Program. Prior to this, she led the Association of American Medical Colleges' policy, advocacy, and data analytic efforts surrounding alternative payment models. She directly supported approximately 60 hospitals’ and provider groups’ efforts to implement Medicare bundled payment programs. Jessica holds an MS in Health Policy and Management from the Harvard School of Public Health and a BA in Political Science from the University of Richmond.
This article was coauthored by Hannah Alphs Jackson, MD, MHSA, director of value-based care and assistant professor of surgery at Northwester Medicine.

On July 10, 2019, CMS announced a new proposed mandatory payment model called the Radiation Oncology (RO) Model. The RO Model would establish a site-neutral prospective bundled payment for 90-day episodes of care for radiation therapy. Unlike other popular CMS bundled payment programs, such as the Oncology Care Model (OCM) and Bundled Payments for Care Improvement (BPCI), the RO Model will only include payments for services directly linked to radiation therapy while excluding payments for hospitalizations and post-acute services (Figure).
Figure: RO Model “Episode”

CMS explains in its proposed rule that the RO Model is designed to test whether a prospective payment model can incentivize the provision of high-value care—in this case, incentivizing the delivery of a shorter course of radiation therapy treatment with more radiation per fraction when clinically appropriate.

The RO Model is slated to start on January 1, 2020, with a potential delay to April 1, 2020. While designing a prospective bundled payment model is a considerable undertaking, implementing such a model is an entirely different ball game. Many commenters have called for a delay to the start date to allow providers to complete the necessary tasks required by many models, such as engaging clinical and operational stakeholders, analyzing data for improvement opportunities, hiring new staff, etc.

As a prospective payment model, the RO Model also includes significant billing changes. This article explores the time and process required to operationalize a prospective billing model, and ultimately shows that neither the January 2020 nor April 2020 start dates provide participants with sufficient time to complete the build.

Summary of New Billing Requirements
RO Model participants are required to bill 2 new Healthcare Common Procedure Coding System (HCPCS) codes that correlate to the prospective payments associated with the professional and technical components of care: (1) when a treatment planning service has been furnished and (2) when  treatment has been delivered.

It’s important to note that, in many instances, 2 different entities will submit these 2 separate codes. “Professional participants” (a physician group practice of whom the treating radiation oncologist is a member) will bill the first code while “technical participants,” such as hospital outpatient departments or freestanding  centers, will bill the second code. Only in instances in which both the professional and technical components are furnished through a freestanding radiation therapyRT center (“dual participant”) would one entity bill both codes.

Finally, CMS also requires participants to bill pre-existing HCPCS codes associated with radiation therapy with no-pay amounts throughout the entirety of the 90-day episode. This requirement will allow CMS to monitor utilization under the model.

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