ROCR FAQs

Education
 

What is ROCR

The ASTRO-proposed Radiation Oncology Case Rate (ROCR) program represents a legislative initiative to reverse disastrous Medicare payment trends that are expected to continue. ASTRO believes ROCR represents the best chance to secure long-term rate stability and continue to deliver cutting-edge care to our patients close to home.

Check out this article and recorded webinar to learn more.

How has ROCR changed since it was first introduced in July? 

Leading up to and during the ASTRO Annual Meeting, we heard from many members and stakeholders that ROCR is the best path forward for ensuring our patients have access to high quality care in both physician offices and hospitals. We also received specific feedback that has led to improvements to ROCR, including:

• Preventing any new CMS cuts by limiting 5-year rebasing declines to no more than -1%.
• Specifying that new technology and services won't be included in ROCR case rates for at least 10 years after acceptance by Medicare and only with broad community support.
• Reducing the episode window from 90 days to 30 days for bone and brain metastases.
• Adding practice accreditation flexibility for small practices, including removal of payment penalty.
• Clarifying that excluded services and non-radiation cancer services and treatments will be paid fee-for-service during an episode.
• Ensuring HEART payments cover rideshare transportation.
• Exempting radiation oncologists from participating in MIPS quality reporting.
• Requesting federal reports assessing ROCR's impact on access to care, including rural and underserved communities, inclusion of new services, and application to Medicare Advantage.

Where can I find more information about ROCR?

ASTRO’s website has a variety of tools including several webinars, policy and technical documents, as well as Excel modeling tools. Practices are encouraged to review these materials and submit questions to health policy team.

Providing Feedback

Is there an opportunity for public comments?

Yes, ASTRO welcomes feedback on ROCR! We want to hear about the model’s potential impact on your practice and the patients you care for. Comments should be submitted to health policy team.

Is there a timeline for ROCR?

ASTRO intends to collect member feedback through the October 2023 ASTRO Annual Meeting. During this time, ASTRO will continue to advocate for fair reimbursement through the current Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment Systems (OPPS), as well as continue our Advocacy on Capitol Hill pushing for payment reform.

Ins and Out

Why are proton therapy, brachytherapy and radiopharmaceuticals not included in ROCR?

Proton therapy treatment delivery codes (77520-77525) are currently not valued under the Medicare Physician Fee Schedule. Payments for proton therapy services are instead determined regionally by each Medicare contractor and vary significantly. Additionally, the volume of traditional Medicare patients treated with proton beam therapy is lower than other modalities. These factors make it very challenging to appropriately value the service within an episode-based payment model.

The delivery of brachytherapy and radiopharmaceuticals are also lower volume services, but they are valued under the Medicare fee schedule. However, the current rates undervalue the services delivered. Therefore, including these services in an episode-based payment model based on recent reimbursement data would only exacerbate current concerns regarding the undervaluation of these services.

These and other radiation therapy services could be included in the model in future years as increased utilization and stable pricing develop.

Why is adaptive radiotherapy not included in ROCR?

Currently, there is not a CPT Code associated with Adaptive Radiotherapy, and therefore CMS has not valued this service. In the future, Adaptive Radiotherapy could be incorporated into ROCR case rates once a CPT code and value are assigned to Adaptive Radiotherapy.

Is there a short time limit until new technology will be included in ROCR case rates? 

It is critical that there be sufficient opportunity for new technology and services to mature in the radiation oncology marketplace before inclusion in ROCR case rates. There is no time limit at which new technology and services must be included in the ROCR case rate methodology. New technology and services, such as adaptive radiotherapy and real time PET-guided radiation, will be paid fee-for-service until there is broad clinical evidence, market penetration, and stakeholder consensus for inclusion in ROCR case rates.

Why are PPS Exempt Cancer Hospitals excluded from ROCR?

In 1983, Congress established an exemption from the Inpatient Prospective Payment System for cancer hospitals that met three criteria: 1) be designated as a comprehensive cancer center (CCC), 2) be organized primarily for treating and researching cancer, and 3) show that at least 50% of its total discharges had a principal diagnosis of cancer or other neoplastic disease. Today, 11 PPS-exempt Cancer Hospitals (PCH) exist.

In 1999, the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBA) passed requiring the Secretary of Health and Human Services to determine OPPS payments for cancer hospitals based on their pre-BBA payment amount. So, while PCHs are not expressly excluded from the outpatient PPS, they receive transitional outpatient payments (TOPs) to maintain their pre-BBA payment amounts.

Because the PPS Exempt Cancer Hospitals are PPS Exempt and paid outside of the MPFS and the OPPS, they are effectively part of a unique Medicare payment system and cannot be included in other payment programs.

Does ROCR apply to freestanding centers?

Yes, ROCR applies to both freestanding and hospital outpatient-based radiation oncology departments. The case rates associated with ROCR are based on historical hospital outpatient rates, rather than freestanding rates, that have seen significant declines in recent years.

Savings

Why does ROCR have to generate savings? Hasn’t radiation oncology been cut enough over the last decade?

Congress is operating under pay-as-you-go rules, making it challenging to pass any legislation that does not reduce federal spending, particularly in the health care policy space. Therefore, to secure Congressional support, ROCR will have to demonstrate savings to the federal government. The $212M is phased in (-3% to -8%) over the first five years of the program and then reduced to -3%. Please note that ROCR would also increase case rate payments annually according to inflationary updates, which would partially offset the phased-in reductions. The $212M equates to $17,500 per practice or a ~1% reduction in Medicare FFS revenue each year. Likely, this amount of savings is less than what radiation therapy would experience due to expected additional rate cuts as early as this summer.

In ROCR, ASTRO estimates savings to be less than what is likely to happen if current payment and hypofractionation trends continue. How does this agree with the ASTRO Work Force Study which predicts RVU stability in future years?

Both ROCR and the Work Force Study considered the same hypofractionation assumptions. However, the ROCR analysis includes impact assessments of all payments, not just work RVUs. The Work Force analysis only considered work RVUs. ASTRO’s analysis indicates that aggregate payments inclusive of professional and technical payments will decline through 2030, owing to greater sensitivity of technical payments due to hypofractionation.

What are the national case rates based on?

The national case rates are based on the M codes for the professional component (PC) and the technical component (TC) of each of the 15 disease sites for the RO Model that CMS issued in the 2022 MPFS final rule. Under the RO Model, CMS determined that HOPPS rates were more accurate for radiation oncology services, so the Agency based the M codes on HOPPS data. ASTRO replicated the methodology and found that those case rates were reasonable and trended them forward to 2024 for ROCR.

How will ROCR ensure stable payments into the future? What stops CMS from pushing back again in 2028?

ROCR’s set base rates and inflationary updates will help ensure stable payments in future years. By making ROCR law, CMS will have much more limited authority than it does currently under the MPFS and HOPPS to adjust radiation oncology payment rates. As long as radiation oncology participates in Medicare, the specialty will be subject to government decision making on health policy, requiring constant advocacy.

Episode of Care

How does ROCR handle incomplete courses of care? For example, if a treatment plan is developed and the patient starts receiving treatment but then passes away before the last treatment is administered? 

A ROCR case rate is paid at two points during the course of treatment. The first half of the payment is made when both the treatment plan and the first treatment delivery take place. The second half is paid at the end of the course of treatment or at 90-days, whichever comes first. In circumstances, in which a patient is unable to complete treatment, the full case rate (both payments) will still be paid. However, the ROCR case rate will not be paid when the treatment plan is completed but the patient is never treated. The work associated with cases that are never treated will be paid FFS.

What other disease sites are paid like this? 

The ROCR concept builds off previous payment reform initiatives, such as the End Stage Renal Disease (ESRD) Prospective Payment System (PPS). Under the ESRD PPS, federal law requires a bundled payment to ESRD facilities (including drugs, labs, supplies, and capital costs) for renal dialysis services furnished to Medicare beneficiaries for ESRD effective Jan. 1, 2011. Correlations can also be drawn between ROCR and other Center for Medicare and Medicaid Innovation (CMMI) episode-based payment models, such as the Better Patient Care Initiative Advanced and the Comprehensive Joint Replacement Models.

How would ROCR deal with multiple treatments within a 90-day episode? For example, a metastatic case where several palliative sites may be treated over a short period of time. 

The ROCR case rates for bone metastasis and brain metastasis cases are inclusive of payments made for all services during a 90-day period, including services for treatment of multiple sites at different times during the 90-day episode timeframe. The case rate payment therefore represents a blended average of single-site and multiple-site palliative episodes and would provide reimbursement when multiple sites are treated during the 90-day period.

Payment Methodology and Billing

How does ROCR prevent future cuts?

ROCR is designed as a separate payment program under traditional Medicare. As a separate payment program, ROCR is designed to live in perpetuity, but has flexibility to shift services in and out of the program through rebased and revised payment methodologies. The model is rebased at five-year intervals. During the rebasing period, changes in technology and the cost of care associated with included or excluded disease sites and radiation therapy services may be incorporated into the methodology, with stakeholder input. However, a guardrail will be implemented through statute that prevents the rebased rates from increasing or decreasing by more than a certain percentage in any one rebasing period, effectively stabilizing future payments.

Would ROCR give practices the flexibility of submitting charges for consultation and simulation if both were done on the same day? 

All evaluation and management (E/M) codes associated with the initial consult would continue to be paid FFS. Simulation services are included in the ROCR case rate.

ROCR generates savings off the Technical Component payments? Won’t that make it less desirable for hospital-based practices?

While ROCR does generate the bulk of its saving from TC payments given the large proportion of radiation therapy services payments made up by TC payments, the reductions in TC revenue likely are less than what is expected if current hypofractionation trends continue. Hospital settings are already seeing declines in TC revenue as a result of hypofractionation, which likely will become more significant unless a new payment program like ROCR is implemented.

Will practices still have to bill CPT codes along with ROCR M codes as part of the claims submission process?

As part of ROCR implementation, CMS will outline the claims submission process. It is likely that CMS will seek to monitor ROCR by requiring the submission of CPT codes, in addition to M codes. This was the plan under the RO Model, and we anticipate there will be a similar requirement under ROCR as well.

ROCR establishes a sustainable payment methodology that recognizes annual inflationary updates while also generating incremental savings through 2028 before transitioning to a flat savings rate of 3% each year into perpetuity. Are these savings assuming reimbursement continues at current fee-for-service levels or do these savings take into account likely decreases in FFS reimbursement over time?

The ROCR base rates are calculated using recent FFS payment data between 2017-2019 that are then adjusted to account for inflation and program savings through 2028. There are no further adjustments made to the base rates to account for ongoing changes in service utilization and Medicare payment policy that would otherwise affect FFS reimbursement. For example, continuation of currently observed trends in hypofractionation or stereotactic therapies would not impact the base rates, which remain fixed for subsequent inflation and savings adjustments.

How is the flat savings rate of 3% in perpetuity calculated if the model only provides reimbursement through 2028? Does this mean that reimbursement under ROCR would be decreased by 3% after 2028 or just that the model would continue to offset annual 3% savings with positive inflationary adjustments after 2028?

After the first five-year period, there will be a rebasing period that sets rates for the next five-year period (2028-2033). ROCR would continue to have stable case rates that are adjusted for inflation each year. The rebasing process would include guardrails that would prevent significant cuts to the case rates. The 3% savings adjustment into perpetuity would apply to the rebased case rates beginning in 2028 and into perpetuity. The offsetting effects of the annual inflationary adjustments and savings adjustments are expected to be approximately net zero and therefore supportive of ongoing stable payments.

How are payments for professional and technical services split?

Professional services and technical services are paid separately under ROCR. Similar to the RO Model, ROCR includes a Professional Component (PC) and Technical Component (TC) payment for each of the 15 disease sites. Below is a chart detailing the PC and TC base rates for each disease site:
 

The PC and TC base rates are based on the M Code rates that CMS established in the 2022 Medicare Physician Fee Schedule (MPFS).  Those rates were based on radiation oncology payment data under the Hospital Outpatient Prospective Payment System (HOPPS) between 2017-2019 and trended forward to 2024. The Centers for Medicare and Medicaid Services (CMS) uses HOPPS data because the Agency recognizes that the payment data under HOPPS better represents the cost associated with delivery of radiation therapy.

How would you handle payment for the initial code, but the patient receives no treatment or treatment terminates after the first fraction?

For those cases in which a course of treatment is planned but there is no treatment delivery, services that are provided will be paid under the current fee for service payment system. However, cases in which treatment plan is developed and one fraction of the treatment is delivered trigger the ROCR case rate, the first bundled payment will be issued. The second portion of the ROCR case rate will be issued even if the patient does not complete treatment.

Would there be a way to bill for different treatment planning for the same treatment service? For example, 3-D vs. IMRT treatment planning for SBRT on CyberKnife vs. traditional linac?

ROCR is modality agnostic so you will not be able to bill for different types of treatment planning associated with SBRT. The cost associated with different types of planning services are already included into the case rate for each related disease site.

Health Disparities and Quality Care

What triggers the HEART Payment and how will it be implemented?

A Health Equity Achievement in Radiation Therapy (HEART) payment of $500 is added to the Technical Component payment when a Medicare beneficiary affirmatively responds to the following question:

In the past two months, has a lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?

Practices will use a Z-code to trigger the HEART payment. The HEART payment will not duplicate other transportation benefits provided under Medicare or Medicaid and will be subject to program integrity rules to prevent abuse.

ROCR incentivizes practice accreditation. Which accreditation standards meet this requirement and will my practice need to complete accreditation before ROCR launches?

In the first three years, ROCR provides a .5% update to the Technical Component payment for practices that either have accreditation or are actively working toward accreditation. The ASTRO APEx Program, the ACR Radiation Oncology Accreditation Program, and ACRO Accreditation Program would meet this requirement. After the first three years, the ROCR methodology applies a -1% reduction to the technical component payment for practices that are not accredited by one of the three accrediting bodies.

Other

If this fails what are the long-term consequences from CMS and the AMA RUC?

Radiation oncology will continue to advocate with CMS and Congress for fair Medicare payment policies for radiation therapy services, regardless of the outcome of ROCR. However, it is expected that radiation therapy will continue to be subjected to payment cuts in the Medicare Physician Fee Schedule, as CMS continues to pursue policies to support primary care and other health care services at the expense of capital-intensive specialties like radiation oncology.

In addition, ASTRO will continue to work with our valued partners at the AMA, including through the CPT and RUC process, and across the House of Medicine to support fair payments for all physician services, including the development and valuation of existing and new radiation therapy services.