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One-year estimated state impact to hospitals of 340B cuts for FFY 2021

The 340B Drug Pricing Program allows qualifying hospitals to offer affordable prescription drugs to financially vulnerable and fragile patients by purchasing outpatient drugs from manufacturers at a discounted rate. These hospitals then can reinvest the savings in their services. In 2018, CMS issued a final Outpatient Prospective Payment System rule that reduced by approximately 25% the reimbursement for certain drugs that hospitals acquired through the 340B Program and then continued those cuts in 2019 through 2022. HHS' 340B cuts are currently being challenged through a lawsuit with the U.S. Supreme Court.  This analysis includes the continued 3.19% budget-neutral adjustment and the 340B reduction (Average Sales Price minus 22.5%) that was identified in the Standard Analytic File with the “JG” modifier, resulting in a net impact. DataGen has analyzed the budget neutrality adjustment and 340B cuts utilizing the 2019 Standard Analytic File showing the potential impact to 340B hosp

How to prepare: Radiation Oncology Model billing guidelines

Commonly asked questions about the Medicare Radiation Oncology Model billing guidelines What are the billing guidelines for the Radiation Oncology Model? RO Model participants must submit claims under the existing Medicare claims system according to the RO Model billing instructions described in the CMS final rule . In addition, RO participants must submit “no-pay” claims for all radiation therapy services furnished in the episode. What are the approved cancer types? The RO Model covers 15 cancer types. These cancer types are commonly treated with radiation therapy under nationally recognized, evidence-based guidelines and are associated with ICD-10 codes that have demonstrated pricing stability. What are the approved modalities of treatment? Modalities covered under the RO Model include three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic radiosurgery, stereotactic body radiotherapy, proton beam therapy and image-guided radiation therapy. What servi

How to prepare: Radiation Oncology Model, Part 1

Check your participation status and build your plan Are you a hospital outpatient department, physician group practice or freestanding clinic providing radiation therapy services? If so, you may be required to adopt the new mandatory Radiation Oncology Model. Mandatory participation is randomized by Core-based Statistical Areas. You can check your organization’s participation status online. CMS released the Final Rule for the RO Model, giving providers 60 days to prepare for program launch on January 1, 2022. If your organization performs radiation therapy in a ZIP code on the list, you will need to begin preparing for the model.

Check it out: The new DataGen Insights newsletter

DataGen has just launched a quarterly newsletter designed to provide relevant healthcare insights to healthcare providers and associations. Each edition will feature a case study, recent industry highlights and information about DataGen products and services all designed to help you stay informed and ahead of the curve. Let us know what you think of our first edition. If there are any topics you would like to see covered in a future newsletter, or if you are interested in learning more about our product suite, please reach out. Download DataGen Insights today . We hope you enjoy!

What to know about CMS’ 2022 rules

Key takeaways from five final and two proposed rules from CMS CMS adopted five final Medicare Prospective Payment System rules for FFY 2022 and proposed two rules for calendar year 2022. DataGen has interpreted and analyzed each of the final and proposed rules to help you gauge how these changes may impact your organization.   These rules include regular updates to the wage index and other significant items listed below. The Inpatient PPS final rule includes the following proposals: rebasing and revising the IPPS marketbasket and the Capital Input Price Index from FFY 2014 cost report data to FFY 2018 data; rate increase (+0.5%) for the Medicare Access and CHIP Reauthorization Act of 2015 coding offset adjustment; nonstandard adjustments to hospital wage indexes (for eligible hospitals) including bottom quartile adjustments, a 5% wage index “stop-loss” and the reintroduction of an imputed floor policy as mandated by the Consolidated Appropriations Act of 2021; updates to Medicare Dis

Proposed rule updates for the Radiation Oncology Model

The new Radiation Oncology alternative payment model will start Jan. 1, 2022, after the proposal is finalized in the calendar year 2022 Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System final rule, scheduled for early November. This rule will require prospective hospital outpatient departments, physician practices and freestanding clinics providing radiation therapy services to adopt a prospective bundled payment model with new clinical and quality measure reporting requirements. The model is mandatory for participants selected by CMS. The new RO model includes several notable changes that must be addressed for successful participation: Disease sites update The criteria for cancer types have been clarified. Cancer types must be: commonly treated with radiation therapy according to nationally recognized evidence-based guidelines; associated with ICD-10 codes that demonstrate pricing stability; and not determined to be unsuitable for inclusion by the H

Your guide for navigating Alternative Payment Models

Alternative payment programs are critical to payment and care delivery transformation. CMS is introducing new alternative payment models that provide opportunities to deliver better value of care and support healthcare innovation in the years to come. Rising healthcare trends should be taken into consideration when evaluating new APMs. Yet, keeping ahead of which programs offer you the greatest opportunity can be a major challenge. DataGen put together Navigating Alternative Payment Models: A User's Guide , offering insights on the participation categories—and detail on programs within each category—this resource can help you determine the best course for your organization’s future. Download our user's guide to learn about new APMs, implications for providers and data-driven strategies for successful pro gram execution.