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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.
The Process to Operationalize New Billing Requirements
While the process may vary slightly across organizations, most will have to undertake a similar process in order to operationalize these new proposed billing requirements. We estimate that the process could take 6 to 9 months to successfully implement. At a high level, the process includes the following steps (which has been taken directly from Northwestern Medicine [NM]’s comments to CMS):
  1. Establish front-end process to identify patients and claims for whom and to which the billing methodology must be applied.
  2. Build logic in Epic to appropriately bundle visits for all treatment plans to ensure accurate tracking and billing.
  3. Build logic in Epic to drop new prospective HCPCS codes.
  4. Build logic to zero out existing  HCPCS codes.
  5. Establish back-end process for updating and posting zeroed out HCPCS codes.
At NM, claims are generated from an automatic field from the Epic Accounts Receivable (AR) System. Thus, in order to submit a zero-dollar claim, charges must be entered as $0 in the AR System. However, doing so would wreak havoc on internal cost tracking as items listed as $0 in the AR System would also be seen as $0 in internal cost accounting. Correcting these entries to ensure accurate budgets, profit and loss statements, and other financial documents would be extremely burdensome.

NM has identified one potential solution to avoid this back-end work: permit the original HCPCS payments to be listed in the “non-covered charges” claim column, while $0 would be entered in the “covered charges” column. This information, along with detailed billing instructions (type of claim form, necessary claim lines, etc), will hopefully be included in the final rule. 

Additional Challenges
The following issues further complicate the operationalization of the proposed billing process (partially taken from NM’s comments to CMS):
  • Coordination between technical and professional participants: In order to ensure that the appropriate codes are submitted with no-pay amounts, professional and technical participants must coordinate their processes. For example, if radiation therapy is first administered on day five of an episode, the technical participant’s billing team must know to only zero out claims for the subsequent 85 days. This unique logic must be established for each patient.
  • Use of third-party billing companies: Many providers and health systems rely on external third-party vendors to complete their billing. RO Model participants will require time to determine how to best partner with these entities to ensure appropriate billing.
NM believes that, when done right, alternative payment models can help further incentivize the efficient delivery of high-quality care. In order for APMs to be successful, providers require sufficient time for planning and implementation. APMs featuring prospective payment carry a unique time-intensive challenges.

If CMS wants providers to execute a new billing system, it must give them the time to do so. At a minimum, the RO Model start date should be pushed back to October 1, 2020.

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