Latest CMS Radiation Oncology Bundled Payment Model Rule Summary

On September 18, the Centers for Medicare & Medicaid Services (CMS) issued a final rule establishing a new alternative payment model (APM) for radiation oncology (RO) services delivered to Medicare fee-for-service (FFS) beneficiaries. The model is mandatory for physician group practices (PGPs), hospital outpatient departments (HOPD) and freestanding radiation therapy centers (RT) that deliver services in randomly selected areas of the country and will begin January 1, 2021.

Here’s a quick rundown of the Radiation Oncology Model.

The RO Model is applicable to PGP’s, HOPD, and RT services based on the participant zip code (RO Model Participating Zip Code List) with a five-year performance period that begins 1/1/2021 (PY1) and runs through 12/31/2025 (PY5).

Pricing includes both discounts and withholds.

  • Discount factors (3.75% for Professional Component and 4.75% for the Technical Component)
  • Withholds*
    • Incorrect Payments (1% for PC and TC), quality (2% for PC)
    • Patient Experience (1% for TC starting in 2023)

*Of which, all or some of the incorrect payment withhold can be earned back and only a portion of the quality and patient experience can be recouped.

The payment is prospective with half of paid at when the RO episode is initiated, and the second half is paid when the episode ends.  Payments are split into the Professional and Technical components.

There are 4 Quality Measures included, which begin in PY1 (see measures below) and the CAHPS Cancer Care Radiation Therapy Survey will be administered starting in 2021 to determine patient experience measures used in PY3-5.  Withholds apply a pay-for-performance methodology with 2 percent of the PC and 1 percent of the TC payments for each episode.

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

Participants are also required to submit clinical data elements for five cancer types (bone, brain, breast, lung, prostate) biannually.  The clinical data requirements will be provided to RO participants prior to the start of PY1.  See Clinical Data Elements Informal Request. For more information, see the CMS Fact Sheet or go directly to the CMS website.