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Major OCM deadline approaching

DATE: 09/22/2020

In response to the COVID-19 pandemic, CMS has implemented several policy amendments and changes to value-based care program methodologies. In June, CMS released new COVID-19-related payment methodology and data reporting flexibilities for Oncology Care Model participants impacting performance periods 7-9, along with establishing two new voluntary performance periods in 2021. The deadline for electing to pursue those changes and for choosing to continue participating in OCM is Friday, Sept. 25.

For the COVID-19-related payment methodology flexibilities, participants can either elect the COVID-19 reconciliation opt-out, or take no action. Practices that choose the former will not be obligated to repay episode expenditures above their benchmark or target amounts, depending on their existing risk arrangements; nor will they be able to earn a performance-based payment for the impacted performance periods.

Participants that choose to take no action will still be eligible to earn a performance-based payment for the impacted performance periods and will remain in their existing risk arrangement. CMS will also remove any episodes that include an inpatient or outpatient claim with a COVID-19 diagnosis from the practice’s or pool’s reconciliation-eligible episodes, along with any non-OCM episodes used in reconciliation calculations.

Participants that remain active through performance period 9 will be eligible to sign a COVID-19 amendment to extend their participation through 2021, covering PP 10 and PP 11. Practices wishing to participate in this extension must sign all required paperwork by Sep. 25 — failure to do so will mean they are not permitted to participate in PP10 and PP11.

Participants attempting to determine which path to take regarding the COVID-19 payment methodology flexibilities should consider the following:

  • Those with one-sided risk should consider the “take no action” approach, as having the impacted performance periods reconciled can only potentially benefit them in this circumstance.
  • Those with two-sided risk need to weigh how likely they are to earn a performance-based payment and if their organization can tolerate that risk. If they are unlikely to earn a PBP or remain in the neutral zone, opting out of the reconciliation is probably the best bet. In contrast, those that have been historically close to earning a PBP should decide how comfortable they are with their experience in the impacted performance periods to go forward with reconciliation excluding their COVID-19 patients.

Participants may face a tougher decision when it comes to the COVID-19 extension amendment. Here are some tips:

  • Those at one-sided risk that have historically earned a PBP should continue to participate.
  • Those at two-sided risk who have historically not earned a PBP should carefully consider their options with leadership. It may be tempting to opt out from a financial standpoint alone; however, staying in the program for the additional performance periods can help further advance practice transformation and prepare the practice for the new Oncology Care First model coming in 2022.

OCM participants have faced many tough financial decisions throughout the course of the program.  As a result of the pandemic, they continue to make difficult decisions while also weighing the costs and predicted future costs of COVID-19, particularly as the fall and winter may bring a surge in COVID-19 cases.

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