Skip to main content

Update on the CMS Radiation Oncology Model


After months of anticipation, CMS is planning to go forward with the mandatory Radiation Oncology Model. This bundled payment model, which was first announced in a proposed rule on July 10, 2019, with an anticipated start in January or April 2020, is notable for being one of the first mandatory models the industry has seen from CMS in years.

While the model has been delayed, in part due to the complications presented by the COVID-19 public health emergency, CMS finally broke its silence on the future of the model in September with the publication of the RO model final rule. A revised start date was announced in the OPPS final rule in December: the RO model is anticipated to begin on July 1, 2021 and will run through 2025.

Key facts:

RO participants include freestanding radiation therapy centers, hospital outpatient departments and physician group practices with radiation oncologists that furnish radiation therapy services. The model is mandatory for selected participants. These were chosen by random selection of Core-based Statistical Areas. Any entities that deliver radiation therapy within the selected CBSAs’ Zip Codes are included in the mandate. According to CMS, the model covers 30% of all eligible RO model episodes in the country.

Radiation therapy episodes are defined as 90-day episodes of care covering radiation therapy services only. This makes sense, as most courses of radiation therapy complete in under 90 days. Unlike previous CMS bundled payment programs, RO is not a total cost of care model. The model includes episodes for 16 cancer types, which primarily target solid tumors.

The RO payment model differs greatly from other Medicare bundled payment programs. Prospective payments will be made to providers who furnish the professional component of the episode (i.e., treatment planning) and providers who furnish the technical component of the episode (i.e., delivery of radiation therapy). The first half of the payment will be paid after the episode begins and the second half will be paid after the episode has ended.

While payment rates will be specific to the component of the episode and the cancer type, they will not vary by site of service. A variety of risk adjustments will also be applied in the creation of each RO participant’s payment rate to account for case mix and historical experience.

CMS will withhold a percentage of the episode payment amount up front, which will be later allocated during reconciliation based on metrics such as quality measure performance and patient experience.

What’s unique about this model?

RO takes several methodological features of prior Innovation Center models and introduces a few new concepts to create a unique evolution of alternative payment models. It marks a striking departure from other bundled payment programs — especially in the way it makes prospectively set payments for the bundle of services. Rather than continuing fee-for-service payments in the interim and settling up to a target price in the reconciliation, RO replaces existing fee-for-service payment structures for radiation therapy episodes. In this way, the RO payment mechanism bears a resemblance to capitated payment arrangements.

What is still unknown?

RO participants are still looking to CMS to release more information in the coming months, including new Healthcare Common Procedure Coding System codes to indicate the start and end of the episode by cancer type. CMS will host a much-anticipated billing guidelines webinar in January.

CMS plans to collect clinical data elements from RO participants beginning in January 2022. These CDEs would include important clinical information about the beneficiary’s disease that is absent from claims data, like cancer stage, treatment intent and dosage of radiation delivered. As practices currently in the Oncology Care Model can attest, this clinical data collection can be burdensome. CMS accepted comments on the currently proposed set of CDEs through mid-October, but industry stakeholders and RO participants are still waiting to hear how this will be finalized for the upcoming model.

There are still plenty of other unknowns clouding RO’s future: COVID-19 continues to surge throughout the country, the public health emergency declaration is likely to be extended again and a new administration takes office in January. All of these things may still impact the revised July 1 start date and the future of the RO model.

It’s going to be interesting to see how RO launches and develops. Levels of enthusiasm for mandatory bundled programs have fluctuated through changes in leadership at HHS over the past five years. It also marks one more alternative payment model focused on specialty care. RO could become the first testing ground for the next evolution of alternative payment models. Specialty care providers should keep a close watch on this program. To learn more about RO and other APMs be sure to contact us and request a free consultation.


Popular posts from this blog

BPCI Advanced – take advantage of the model extension now

The Bundled Payment for Care Improvement (BPCI) Advanced Model is now open for applications until May 31, 2023. This model provides a unique opportunity to acute care hospitals and physician group practices who are looking to: evaluate their bundle performance; rejoin if they have previously dropped out due to being under a convener; or take advantage of the changes to the model. With a small window to sign the participation agreement, you’ll need experts to process data quickly and accurately for evaluation. BPCI Advanced Program Details The Centers for Medicare & Medicaid Services (CMS) announced in October 2022 that this program will extend from January 2024 to December 2025. Data used for evaluation will be taken from the baseline period between October 2018 and September 2022. A participation agreement will be sent out in September 2023 and needs to be signed by October 2023 in order to participate. Those who apply before the May 31 deadline will benefit

BPCI Advanced Model Extension

CMS recently made several major announcements about the Bundled Payments for Care Improvement Advanced Model.  The model, which was due to expire at the end of 2023 (Model Year 6), will be extended for an additional two years through Dec. 31, 2025.  New applications will be accepted in 2023 for the two-year extension. Participants still active in Model Year 6 can continue without reapplying by signing an amended and restated participation agreement for Model Year 7.  New methodological changes will be implemented for Model Year 6, which starts on Jan. 1, 2023. Methodological changes include that: the CMS Discount Factor for medical clinical episodes will be reduced from 3% to 2%;  the Peer Group Trend Factor Adjustment cap for all clinical episodes will be reduced from 10% to 5%; the Major Joint Replacement of the Upper Extremity clinical episode category will become a multi-setting episode category by allowing episodes to be triggered when the procedure is performed in the hospital ou

You’ve been accepted to the Enhancing Oncology Model. Now what?

The Centers for Medicare and Medicaid Services Innovation Center recently announced approved applicants for the new Enhancing Oncology Model. If your facility has been selected by CMS, are you still weighing your options during the current baseline evaluation period?  Two deciding factors may include the program data that CMS provides and whether EOM is enough of an improvement over the prior Oncology Care Model to make your investment worthwhile. Another factor to consider: Will you have the resources in place to conduct a baseline evaluation before EOM’s program start on July 1, 2023? How EOM differs from OCM EOM aims to improve the coordination of oncology care, drive practice transformation and reduce Medicare fee-for-service spending through episode-based payment. It includes three major updates: Fewer cancer types. Compared with OCM’s 21, EOM will be limited to seven common cancer types: breast, prostate, lung, small intestine/colorectal, multiple myeloma, lymphoma and chronic le