NEW Radiation Oncology Alternative Payment Model
The RO Model was released in September 2020, with a projected start date of January 1, 2021. Find out more on the RO Model webpage.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Quality Payment Program (QPP). QPP transitions Medicare payment away from fee-for-service to pay-for-performance, emphasizing quality care. The program represents a significant change in the way all physicians, including radiation oncologists, are paid by Medicare.
Participation in the QPP is split between the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM); however, within those two branches is a lot of variation. ASTRO has found that many radiation oncology practices may fall into a middle ground of MIPS APMs, which include Accountable Care Organizations (ACOs). The following pages provide a deeper dive into the details of each model:
CMS evaluates eligibility based on where a practice has reassigned billing rights in the Provider Enrollment, Chain, and Ownership System (PECOS). ASTRO recommends that all practices confirm information in PECOS annually.
Physicians can look up eligibility and reporting requirements on the QPP website using their National Provider Identification (NPI) number. Information will include CMS’s analysis of the number of Tax Identification Numbers (TINs) associated with your NPI including MIPS eligibility, APM enrollment, hospital-based designation (more than 75% of services are billed at the hospital), and small practice designation (15 or less eligible clinicians) and facility-based scoring. This information will be provided for both the individual (NPI) and group-level (TIN). This is a valuable resource to determine clinician specific program requirements, as well as ensure that CMS has the correct information regarding your practice.
To date there have been four program years with varying requirements.
- 2020 - This performance period marks a significant year of change fro radiation oncology practices. Starting in 2020 a radiation oncology-specific APM will start, which will broaden the participation possibilities. Regular changes have continued within the MIPS program, including increased participation requirements. Eligible clinicians who choose not to comply with MIPS during the 2020 period are subject to a 9% payment reduction in 2022.
- 2019 – Eligible clinicians who chose not to comply with MIPS during the 2019 performance period are subject to a 7% payment reduction in 2021.
- 2018 – Eligible clinicians who chose not to comply with MIPS during the 2018 performance period are subject to a 5% payment reduction in 2020.
- 2017 – Eligible clinicians who chose not to comply with MIPS during the 2017 performance period are subject to a 4% payment reduction in 2019.
An eligible clinician’s data could have been submitted to CMS for evaluation in three different ways: Individual, Group or APM. It is common in radiation oncology for more than one score to be associated with an NPI or even a TIN/NPI combination.
Score and Payment Attribution
For groups who submitted data using their TIN identifier, the group’s score will be applied to all eligible clinicians that billed under that TIN during the performance period.
An APM score is assigned to all MIPS eligible clinicians participating during the performance period.
If an individual clinician is a participant in a MIPS APM and the group reports to MIPS independently from the APM, then two scores (group and APM) would be associated with the same TIN/NPI. However, only one score is assigned to each unique TIN/NPI combination to calculate and apply a payment adjustment for that specific TIN/NPI. If multiple scores are associated with a TIN/NPI combination, the following hierarchy is used to assign one score:
- If an eligible clinician is a participant in a MIPS APM, then the APM score is used instead of any other score.
- If an eligible clinician received more than one APM score, then the highest score will be used.
- If an eligible clinician reported both as an individual and through a group and is not part of an APM, the higher of the two scores will be used.
MIPS APMs and ACOs
Many radiation oncology practices may be part of Accountable Care Organizations that have different reporting requirements under the Quality Payment Program.
ASTRO is committed to developing quality measures that are meaningful and relevant to radiation oncologists through independent development efforts. ASTRO’s goal is to continue incorporating these measures into the MIPS program.