Cancer Episode Program

Boost your practice’s value-based care model and earn rewards when you help reduce the total cost of care. The Cancer Episode Program is a voluntary bundled payment program that modifies the standard fee-for-service payment system with a prospective, episode-based bundled payment (or episode fee) for 4 months of outpatient treatment. 

Member Eligibility

  • Age 19 or older with primary coverage commercial plans that require prior authorization for cancer therapies1
  • Patients who receive intravenous/injectable chemo with specific cancer diagnoses
    • Breast, colorectal and lung cancer of any stage
    • Most metastatic, solid tumor cancers
    • Certain hematologic syndromes/malignancies
    • Central nervous system cancers

Physician Eligibility

  • Can be a private practice or hospital-based oncology health care professional
  • Has an existing contract with UnitedHealthcare,1 and signs a contract amendment for the program (renewable every 3 years)

Treatment Flexibility

  • Patients can be treated with any National Comprehensive Cancer Network (NCCN)-approved regimen for the specific cancer and stage
  • UnitedHealthcare plays no role in determining which treatment plan oncologists choose

How to participate

  1. Email UnitedHealthcare to indicate you’d like to participate2. Include your practice/facility name, tax ID number(s) and contact information in your request.
  2. We’ll set up time to answer any questions, review the contract amendment and determine a program effective date.
  3. Once you return the signed amendment, your enrollment will be confirmed within 1 week.
  4. During the program kick-off meeting, we’ll work with you to identify your patients who will be automatically enrolled on your program effective date. Patients must be enrolled in a UnitedHealthcare commercial plan that requires prior authorization for cancer therapies. Patients may be excluded for certain customer plans, UnitedHealthcare entities or third-party arrangements.

How Cancer Episodes work

Once your practice is enrolled in the program and the contract amendment is in place, much of the workflow is automated2:

  • Auto-enrollment based on the UnitedHealthcare chemotherapy prior authorizations you’re already submitting
  • UnitedHealthcare will manage patient eligibility within the program
  • Terminations and disenrollment if member eligibility changes

Reimbursement

Prospective episode fee: Covers 4 months of outpatient cancer care and includes:

  • $275 case management fee
  • A standard fee based on margins from injectable chemotherapy and supportive care medications prescribed for the patient’s cancer (does not change based on drugs administered to individual patients)

Intravenous/injectable chemotherapy and supportive care drugs: Paid at 100% of the average sales price (ASP). All other services are reimbursed according to your existing fee-for-service contract.

Renewable fees:

The episode fee is renewable based on the cancer type and stage:

  • Metastatic or relapsed cancers: Every 4 months for patients who may be treated for indefinite periods
  • Hematologic malignancies: Renewed every 4 months while the patient is receiving intravenous/injectable chemotherapy
  • Adjuvant treatment: Renewed every 4 months with a cap on the number of episodes allowed per patient 
  • Maintenance therapy: If the patient requires additional maintenance therapy beyond the adjuvant treatment plan, claims will be processed according to the existing fee-for-service contract

Shared savings:

An annual shared savings payment is made if you help reduce the total cost of care by meeting performance measures, shared savings criteria and targets.1

  • Shared savings payments are separate from and not tied to episode fee payments
  • UnitedHealthcare shares 12 months of medical cost data to review against improvement goals and help you identify opportunities to improve cost and quality outcomes

Questions?

Email cancer_episode@uhc.com.


Disclaimer
UnitedHealthcare reserves the right to change, cancel or modify the program and its features, including reward eligibility, at any time and to temporarily suspend the program at any time without prior notice. If there is any suspected fraud or abuse, UnitedHealthcare reserves the right to stop or discontinue reward payment(s).
Footnotes
1See Program Manual for additional detail on rules. This is not an exhaustive list and is subject to change. Eligibility varies by health plan and state and is subject to all applicable laws and regulations.