Oncology Care Model
Note: If you did not register for the CMS OCM during the open application and selection period, then you are not a part of this program. The names of those practices and payers participating in OCM can be found on the OCM website.
Table of Contents
Overview
The CMS OCM is an innovative, multi-payer model focused on providing higher quality, more coordinated oncology care. Under OCM, physician group practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. The practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries, such as care coordination and navigation, and to using national treatment guidelines for care. OCM is a five-year model that began on 7/1/2016, and runs through 6/30/2021.
After an open application and selection period, nearly 200 physician groups and 17 payers, in addition to CMS, are participating nationally in OCM. Practice participants are Medicare-enrolled physician groups identified by a single TIN and composed of one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. Other payers are commercial insurers that will align their oncology payment models with Medicare’s model and support OCM practices in their practice transformation efforts.
Payments
OCM participants receive regular Medicare FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices, creating incentives to improve the quality of care and furnish enhanced services for beneficiaries undergoing chemotherapy treatment for a cancer diagnosis. These two forms of payment include:
- monthly enhanced oncology services payment of $160 per-beneficiary for delivery of OCM enhanced services, and
- performance-based payment for OCM Episodes
HCPCS code G9678, OCM MEOS payment for enhanced care management services for OCM beneficiaries, has been created for this demonstration. MEOS covers care management services for Medicare beneficiaries in a six-month OCM episode of care triggered by the administration of chemotherapy. Enhanced care management services include services driven by the OCM practice requirements, including: 24/7 clinician access, use of an ONC-certified EHR, utilization of data for quality improvement, patient navigation, documentation of care plans, and use of clinical guidelines. (G9678 may only be billed for OCM beneficiaries by OCM practitioners.)
The MEOS payment for enhanced services provides participating practices with financial resources to aid in effectively managing and coordinating care for Medicare FFS beneficiaries. The potential for a performance-based payment encourages participating practices to improve care for beneficiaries and lower the total cost of care over the six-month episode period. The performance-based payment will be calculated retrospectively on a semi-annual basis based on the practice’s achievement on the OCM quality measures and reductions in Medicare expenditures below a target price.
Episode Definition
OCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary’s chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode.
Innovation Center
OCM was developed by the CMS Innovation (the Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center to test innovative payment and service delivery models to reduce program expenditures and improve quality for Medicare, Medicaid, and Children’s Health Insurance Program beneficiaries.
How to Contact the CMS OCM Team
For questions about the model, or to contact the CMS OCM Team, visit CMS Oncology Care Model or email OCMsupport@cms.hhs.gov.
Providers should contact the CMS OCM Team for any questions and/or concerns’ regarding claim denials stating this provider was not certified/eligible to be paid for this procedure/service on this date of service.
Reviewed 11/2/2023