Radiation Oncology Model: Who must participate

By Featured article

Beginning Jan. 1, 2022, the Centers for Medicare & Medicaid Services (CMS) will implement the Radiation Oncology (RO) Model, a prospective, five-year episode-based payment model, for some Radiation Therapy (RT) providers. The implementation of this model will not be extended unless there is Congressional action. The final rule for the payment system update is posted here. Approximately 30 percent of all eligible Medicare fee-for-service RT episodes will be covered under this model.

CMS also adopted an Extreme and Uncontrollable Circumstances (EUC) Policy to allow them to make adjustments (example: extreme weather like a hurricane, could change requirements for certain ZIP codes or the date of the end of the Public Health Emergency – PHE – for the U.S.).  Providers should monitor the Radiation Oncology website to understand any changes. 

How do I know if I am a participant?
CMS randomly selected Core-Based Statistical Areas (CBSA) through the country and linked ZIP codes to specific CBSAs included in this model for 2022.  Providers need to review the Excel ZIP code file to see if your providers are required to participate.

There are some participant exclusions based on your state, so it is important to review the Final Rule to see those exceptions (particularly those participating in a rural health model in Pennsylvania).

There are three types of participants: Professional (Medicare-enrolled group practice identified by single TIN, furnishing the professional component); Technical (Medicare-enrolled center identified by single TIN or Single CMS Certification Number, providing the technical component); or Dual (Medicare-enrolled practice providing both the professional and technical components of RT). Most community practices are in the Dual participant category.

How can I opt-out?
There is an opt-out clause that notes that any RO participant can opt out on an annual basis if they furnish less than 20 episodes across all the selected CBSAs in a calendar year two years prior to the start of the Performance Year. If eligible to opt-out, your practice must notify CMS prior to January 1 of the Performance Year – otherwise you must report.

NOTES: 
CMS adopted an EUC policy that allows it to adjust model performance periods, reporting requirements, and/or payment methodology.  Unless the HHS Secretary ends the PHE prior to Jan. 1, 2022, the RO modifications listed below for Performance Year (PY) 1 (2022) will go into effect. Practices are strongly encouraged to monitor the RO Model website for any changes.

  • Participants will not be required to actively engage with an AHRQ-listed patient safety organization but will be required to do so in PY 2 (2023). If a relationship does not currently exist, practices should review this requirement and engage with an AHRQ-listed safety organization in 2022.
  • Participants will not be required to conduct Peer Review (audit and feedback) on treatment plans. The details of this peer review process are in the FAQs on the Radiation Oncology website. It is recommended that practices consider doing the peer review in PY 1 to familiarize themselves with the requirements.
  • The requirement that participants collect and submit quality measures and clinical data elements will be optional for 2022. Practices are encouraged to consider entering their quality measures and clinical data elements for PY 1 to familiarize themselves with the process.
    • The 2 percent quality withhold will not be applied to professional episode payments in 2022 since quality reporting is optional.

     

    The InfoDive® team provided an extensive high-level overview of the Radiation Oncology Model Final Rule in a webinar in mid-November. The team highlighted how InfoDive can provide actionable analytics to make informed decisions for your practice, including the creation of an RO episode for every patient with treatment planning or an RO model simulation. Watch the webinar here.  For questions or more information about how InfoDive can help your practice with actionable insights for decision-making, contact the team at InfoDiveSupport@Intrinsiq.com.