RO APM

What is the RO APM?

The RO APM is an advanced alternative payment model developed by the Centers for Medicare and Medicaid Services (CMS) in conjunction with their Center for Medicare and Medicaid Innovation. Under this model, Medicare pays providers a predetermined, site-neutral bundled rate for most radiation therapy services provided within a 90-day episode of care, rather than paying for each service individually. The model would be mandatory for providers selected to participate. The intended goal is to incentivize providers to deliver radiation therapy services more cost-effectively while maintaining or improving the quality of care delivered.

Elekta is actively evaluating MOSAIQ Plaza, our suite of digital tools, to develop solutions that will support customers through the transition and implementation of the RO APM. CLICK HERE to request a demo and learn how MOSAIQ Plaza can help you today.

 

Education & Training


Elekta will provide comprehensive webinar(s) discussing the final rule and what Elekta is doing to assist our customers with this alternative payment model. Contact your local sales representative for more information.

Brachytherapy RO APM webinar: Wednesday, October 21, 2020 12pm EDT

https://success.elekta.com/2020-Brachytherapy-LandL-Series

CMMI RO APM 101 webinar: The CMMI Radiation Oncology (RO) Model team will host a RO Model 101 webinar to provide an in-depth look at the recently finalized RO Model.

https://innovation.cms.gov/ro-model-101

FAQs

A: The RO APM is an advanced alternative payment model developed by the Centers for Medicare and Medicaid Services (CMS) in conjunction with their Center for Medicare and Medicaid Innovation. On September 18, 2020, CMS released the RO APM final rule, which will go into effect on January 1, 2021.

Under this demonstration project, Medicare pays providers a predetermined, site-neutral bundled rate for most radiation therapy services provided within a 90-day episode of care, rather than paying for each service individually. The model is mandatory for providers in the zip codes selected to participate and is intended to incentivize providers to deliver radiation therapy services more cost-effectively while maintaining or improving the quality of care delivered.

A: The RO APM is several years in the making, starting in December 2015, when Congress passed the Patient Access and Medicare Protection Act (PAMPA), which required the Secretary of Health and Human Services to submit to Congress a report on “the development of an episodic alternative payment model” for RT services.

In November 2017, CMS released a report to Congress detailing options for an episodic model for RT services and then, in July 2019, CMS released a proposed rule detailing the specification for the model, which were open to comment until September 16, 2019. Elekta, along with over 300 other providers, patient groups, industry groups, and physician specialty societies, namely ASTRO, submitted comments supporting or disagreeing with various aspects of the model and recommending changes that should be made in the final rule, a few of which were incorporated, while others were not. It is important to note that there are several areas of outstanding advocacy still associated with the model including multiple tumor sites being paid at the primary tumor site rate, and multiple modalities included in one bundle payment.

A: All technologies used during a radiation therapy episode are included in the RO APM per the final rule. This includes external beam (3D, IMRT, SRS, SBRT, IGRT), brachytherapy, and proton beam. The final rule includes an exemption for patients undergoing proton beam therapy that enrolled in a federally funded randomized control trial.

A: Participation in the RO APM is determined by core based statistical area (CBSA) which draws geographically similar areas by zip code. Thirty percent of all episodes of care for RT in the model and hopes to geographically match CBSAs both in and outside the model. All providers, hospitals, and freestanding centers furnishing RT services within a given CBSA are required to participate.

A: This is only for Medicare fee for service patients. Patients with Medicare Advantage, Medicaid, or commercial insurance are not paid under this model. Sites in Maryland and Vermont, prospective payment system exempt cancer hospitals, ambulatory surgical centers, and critical access hospitals and those with the Pennsylvania Rural Health designation are exempt from participating in the model.

A: The final RO Model includes a "low volume opt-out" for any physician group practice, freestanding radiation therapy center, or HOPD that has fewer than 20 episodes in one or more of the selected CBSAs in the most recent year with claims data available.

A: Payment under the RO APM will be assigned based on the diagnosis of the patient instead of the technology used to deliver care, meaning that payment will be technology agnostic. There are 16 cancer types covered by the RO APM which will be tracked via ICD 10 codes. These sites are inclusive of all standard cancer disease sites except for skin. RT services furnished for the treatment of diseases outside of these disease sites, including skin cancer, are excluded from the RO APM and will be paid under traditional Medicare FFS.

The disease sites are:

Anal Cancer CNS Tumors Pancreatic Cancer
Bladder Cancer Colorectal Cancer Prostate Cancer
Bone Metastases Head and Neck Cancer Upper GI Cancer
Brain Metastases Liver Cancer Uterine Cancer
Breast Cancer Lung Cancer  
Cervical Cancer Lymphoma  

A: CMS calculated national base rates for the technical and professional component for each of the 16 cancer types under the model using historical hospital outpatient billing data from 2016 to 2018. Payment under the RO APM will be site neutral, meaning that payments in the freestanding radiation therapy centers will be calculated using the same methodology as hospital outpatient departments.

A: Under the RO APM, participants will receive a single bundled payment for almost every radiation oncology service provided in a 90-day episode of care. A treatment planning code will trigger the start of the 90-day episode. Participants will receive 50 percent of the bundled payment at the start of the episode and 50 percent of the bundled payment at the end of the episode or when the end of episode modifier is billed when the last fraction is delivered. The 90-day episode will be followed by a 28-day clean period in which any services delivered will be paid fee for service (FFS). After the 28-day clean period, a new bundle can be triggered.

A: Elekta will continue to support ASTRO, the RO APM, and bundled payment systems more generally. We understand that, due to current circumstances, it is reasonable to request a delay of implementation to July 1, 2021.

A: Both providers and hospitals in selected zip codes are required to participate. There will be three types of participants in the RO APM:

  • Professional: Individual physicians or physician groups billing under PFS that furnish just the professional component (physician-dependent services) at a freestanding center or hospital outpatient department
  • Technical: Hospital outpatient departments or freestanding centers that furnish only the technical component (equipment, overhead, etc.) of radiation therapy; and
  • Dual: Dual participants are typically in the freestanding setting and may be used when the providers performing radiation also own the location where it is delivered, meaning they furnish both the technical and professional components.

A: The RO APM model methodology is site-neutral meaning payment by established using a common, adjusted national base payment amount for the episode, regardless of the setting where it is furnished. This means that the base rates for both the freestanding and hospital outpatient setting will be the same and the payment methodology is not dependent on the site of service.

A: The RO Model is an Advanced APM and a MIPS APM under QPP. RO APM participants need to annually certify their intent to the use of Certified Electronic Health Record Technology (CEHRT), include quality measure performance as a factor when determining payments, and bear more than a nominal amount of financial risk. RO Model participants who are APM Entities and eligible clinicians seeking Qualifying APM Participant (QP) status in an Advanced APM must comply with all RO Model requirements in order to be eligible for Advanced APM incentive payments. Participants who do not meet the QP threshold would not qualify for the Advanced APM incentive payment and instead would be in a MIPS APM.

A: As a qualified advanced RO APM under MIPS/MACRA, MOSAIQ can be used to report on and submit on the four quality measures required under the RO APM. Because exact requirement for requirements are still being determined, additional information will be needed to determine exactly how CMS would like the quality measures and data submission requirements uploaded for review. Elekta is working closely with ASTRO and others to determine what data elements will be required for reporting and determine appropriate submission vehicles.

A: Elekta is wholly engaged in understanding the requirements of the RO APM and is in the process of updating our MOSAIQ software to allow for reporting and submission of the four quality measures and data submission requirements for the RO APM. In addition, Elekta is making enhancements to other solutions to better allow for our customers to track, submit, and optimize workflows to better accept a bundled payment arrangement.

Additional Resources

Disclaimer

Responsibility for compliance with the Radiation Oncology Alternative Payment Model’s (RO APM) regulations and guidelines rests entirely with the eligible professional or delegate.

Elekta makes no representation of expertise in the Radiation Oncology Alternative Payment Model (RO APM). Elekta advises each eligible professional or delegate to seek its own counsel or advisors in determining how best to interpret, apply, and comply with the Radiation Oncology Payment Model (RO APM) objectives.

Any training and documentation provided by Elekta are for informational and reference purposes only. Elekta makes no representation, warranty, or guarantee of completeness, accuracy, applicability, or validity of the training and documentation provided. Elekta disclaims liability for any loss or claimed damages that may arise from reliance on or use of information contained in any training and documentation provided by Elekta.

Elekta makes no representation, warranty, or guarantee that an end user of the MOSAIQ® oncology information system will meet the requirements for RO APM or demonstrate adequate compliance with the Radiation Oncology Alternative Payment Model (RO APM).