Blog Post

CMS’s New Radiation Oncology Model: What Should I Do Next?

Cmss New Rad Onc Model What Should I Do Next Web

Last month, CMS announced a mandatory bundled payment program for hospitals and physician groups across the country. Against the backdrop of a looming presidential election and a global health pandemic, the announcement of the radiation oncology (RO) model was an unprecedented move and caught providers by surprise.

Now that we’re a few weeks removed from the initial announcement, it’s time for cancer center leaders and providers to roll up their sleeves and figure out how to get ready for this program, which begins July 1, 2021. (Although the RO model was originally slated to begin January 1, 2021, CMS announced on October 22 that it had received feedback from a number of stakeholders about the challenges of implementing the model by that date. Based on this feedback, CMS intends to delay the RO model start date to July. CMS will pursue a rulemaking to make this change.) This blog post will outline the key considerations and immediate next steps for your organization to ensure you are prepared. Specifically, we will help you:

  • Determine whether your organization will be required to participate.
  • Understand new operational processes your program will need to implement (billing, reporting).
  • Engage and educate your physicians and staff.

Determine whether your organization will be required to participate or if you qualify for any exemptions.

The program includes physician group practices (PGPs), hospital outpatient departments (HOPDs), and freestanding radiation oncology centers; ASCs are exempt. However, CMS did not make it explicitly clear which specific provider organizations will be mandated to participate (names, CCNs, and/or TINs were not made available). Instead, they posted a list of zip codes based on core-based statistical areas. If your organization furnishes radiation therapy services for select cancer types and modalities in one of the listed zip codes,[1] you will be required to participate.

One exception to the rule: CMS has offered a low-volume opt-out. If your provider organization furnished fewer than 20 radiotherapy (RT) episodes during CY 2019, you can opt out. If this applies to your organization, CMS will contact you directly (likely via the Radiation Oncology Administrative Portal—more on this later) to offer this option. It is important to note that a failure to formally opt out will result in automatic participation in the program. The opt-out attestation must be performed every year, given potential fluctuations in volume (i.e., you may qualify for the opt-out this performance year [PY] but not next PY).

The Radiation Oncology Administrative Portal (ROAP) will be integral in exchanging information between CMS and participating organizations, and each provider organization that furnishes RT services in the specified zip codes should register. Even if you plan to utilize the low-volume opt-out, your organization will still be required to register with ROAP so you can attest to such opt-out. In order to register for ROAP, you will need both your model ID and TIN or CCN.[2] Please refer to ECG’s Decision Tree below for a complete summary of each step in the participation and portal registration process

Understand new operational processes your program will need to implement.

Participation in the model will require your organization to adopt new processes and procedures, specifically those related to: (1) billing and revenue cycle processes and (2) clinical informatics and reporting workflows.

Billing. The RO model is a prospective bundled payment program and therefore will necessitate new billing requirements that allow a participant provider to denote the start and end of the episode. Your organization will need to work with your billing and revenue cycle team to implement the new provisions, as outlined below. Note that CMS will distribute the prospective payment in two equal parts: 50% at episode initiation and 50% at episode end.

  • To initiate the episode and receive the first half of the prospective payment: Participants will need to bill a new “start of episode” (SOE) modifier along with the model- and cancer-specific CPT code for episode initiation. Both professional providers (i.e., physicians, oncologists) and technical providers (i.e., providers or suppliers of RT services) will need to submit an SOE modifier.
  • Throughout the episode: Participants will bill “no pay” encounter codes throughout the episode so that CMS can track utilization. “No pay” codes indicate that a service is occurring but will not be reimbursed in a traditional fee-for-service manner.
  • To end the episode and receive the second half of the payment: Participants will bill an “end of episode” (EOE) modifier along with the model-specific CPT code. The EOE modifier can be billed at any point (at end of treatment or at 90 days, whichever may be less burdensome for the provider). Regardless, at reconciliation, CMS will consider all episodes to be 90 days in length.

Informatics and Reporting. In addition to billing, participants will need to quickly ramp up their clinical informatics capabilities and reporting workflows. The RO model requires an extensive amount of quality tracking and reporting. First, professional participants must track four quality metrics and manually submit their scores via ROAP every March, following the performance year. In addition, participants will need to submit “clinical data elements” every six months, also via ROAP, beginning July 2021.

Therefore, it is critical to ramp up quickly and begin tracking and measuring quality metrics and clinical data elements as of January 1, 2021. Rather than reporting being focused on the program population, CMS is requiring that metrics be reported for all patients in your practice, regardless of payer. Quality metrics include:

  • Oncology: Medical and Radiation: Plan of Care for Pain—NQF #0383; CMS Quality ID #144.
  • Preventive Care and Screening: Screening for Depression and Follow-Up Plan—NQF #0418; CMS Quality ID #134.
  • Advance Care Plan: NQF #0326; CMS Quality ID #047.
  • Treatment Summary Communication: Radiation Oncology.

It is CMS’s intention that clinical data elements will be “seamlessly” extracted from your EHR; however, we expect organizations will have to make EHR adjustments to track and report this data. Clinical data elements are data not tracked in claims or quality metrics and will only apply to RO participants for five specified cancer types.[3] CMS will announce the required clinical data elements by the start of PY1.

Additionally, CMS will begin initiating the CAHPS Cancer Care Survey in April 2021. CMS will conduct the survey via a contractor and therefore assume responsibility for its cost. Although the survey is being initiated in PY1, the results will not be applied to the participant’s overall quality score until PY3. Providers should focus the next two years on improving patient experience measures that affect the results of the CAHPS score to maximize success in PYs 1, 2, and 3.

Finally, participants will have the option to request data reports from CMS to track their performance at any point during the program. Via ROAP, participants may request claims data at the beneficiary, episode, and/or participant level. To be successful, your organization should develop a process and plan for requesting and analyzing data: at what frequency will you request data? How will you analyze data? Who will it be shared with? What actions will you take based on the findings?

In the next few months, it will be critical to develop an operational plan for both billing and quality tracking. The RO model has many administrative burdens for providers, and ECG can help your organization navigate the waters. We have helped providers successfully implement other CMS programs, including MSSP, CJR, and BPCI Advanced, and we understand the processes required to ensure your program achieves success.

Engage and educate your physicians.

Prior to the RO model start date on January 1, 2021, it will be important to engage your physicians, providers, and other related staff to ensure your program runs effectively. Particularly for the professional component of the program, physicians will have a direct impact on your organization’s performance. It is important that they are highly engaged and well informed of the program and its impacts prior to the start date.

  • Educate Your Physicians: Provide education and information on the program to your physicians as soon as you can. Convey how their role may impact performance and the importance of their engagement throughout the program.
  • Identify a Physician Champion(s): Appoint a highly engaged oncologist to be the “physician champion.” This person will advocate for the physicians in the program and be a source of knowledge for physicians who may have questions or concerns. They will also support physicians in acclimating to any new processes or workflows.
  • Enable Care Process Change: Physician engagement will be critical in evaluating and updating care processes and other workflows, as needed, for the RO model. Empower your physicians to drive change and commit to establishing evidence-based protocols.

Completion of these action items will ensure your organization is set up for success upon program implementation on January 1, 2021. These are operational, tangible items that—with the right teams in place—can be executed immediately.

Looking Ahead

The RO model marks a significant departure from CMS’s historical fee-for-service payment approach and solidifies its shift toward value-based care. We believe that CMS will continue to accelerate these initiatives and launch more mandatory bundled payment programs in the future. As such, organizations should start evaluating their current competencies and capabilities and preparing for a future with more alternative payment models (APMs). ECG’s value-based readiness assessment is your guide for getting started. We can help you achieve success in the RO model and any other APMs that may come your way.

Do you have questions about CMS’s new radiation oncology model? Contact our team with any questions you would like us to address.

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  • 1.

    Cancer types include: anal, bladder, bone metastases, brain metastases, breast, cervical, CNS tumors, colorectal, head and neck, liver, lung, lymphoma, pancreatic, prostate, upper GI, and uterine. Modalities include 3-dimensional conformal RT, intensity-modulated RT, stereotactic radiosurgery, stereotactic body RT, proton beam therapy, image-guided radiation therapy, and brachytherapy.

  • 2.

    To obtain your model ID, call the CMS Help Desk at 844-711-2664, option 5. Be ready to provide your TIN or CCN number.

  • 3.

    Participants will report clinical data elements for the following cancer types: prostate, breast, lung, bone metastases, and brain metastases.