CMS has released the Radiation Oncology Model (RO Model) final rule which will be effective Jan 1, 2021. Episode payments will be paid prospectively in the RO Model, meaning that half of the episode payment amount is paid when the RO episode is initiated, and the second half is paid when the episode ends.
Participant-specific payment amounts are determined based on national base rates, trend factors, and adjustments for each RO participant’s case-mix, historical experience, and geographic location. CMS further adjusts payment amounts by applying a discount factor. The discount factor, or the set percentage by which CMS reduces an episode payment amount, reserves savings for Medicare and reduces beneficiary cost-sharing. The discount factor for the PC is 3.75 percent, and the discount factor for the TC is 4.75 percent. The payment amount is also adjusted for withholds for incorrect payments (1 percent for PC and TC), quality (2 percent for PC), and patient experience (1 percent for TC starting in 2023). RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY. RO participants have the ability to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and the beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey. The standard beneficiary coinsurance and sequestration policies remain in effect.
Beneficiaries are still responsible for the same cost-sharing requirement as under the traditional payment systems (e.g., typically 20 percent of the Medicare-approved amount for services), but because CMS applies a discount to each of these components, beneficiary cost-sharing may be, on average, lower relative to what typically would be paid under traditional Medicare FFS.
The final rule can be accessed here. Or for more on the RO Model, please contact New Bedford today.